Federal Reports

The VA Office of Inspector General (OIG) reviewed concerns related to the Patient Safety Program at the Tuscaloosa VA Medical Center (facility) and programmatic oversight provided by facility and Veterans Integrated Service Network (VISN) 7 leaders. While conducting a separate healthcare inspection at the facility, the OIG received a Veterans Health Administration (VHA) Issue Brief identifying Patient Safety Management Program concerns, including the failure to complete approximately 160 reported patient safety incidents within the required 14 days. These concerns followed the extended leave and abrupt retirement of the former Patient Safety Manager (PSM). Additional failures included not completing the required patient safety root cause analyses and risk assessments, and the former PSM not attending meetings with facility and VISN committees.The OIG substantiated the concerns, which the former PSM attributed in part to lack of support, supervisory engagement, and resources, and identified other concerns with program oversight and the facility’s culture of safety. The facility had multiple pathways for oversight but missed opportunities to identify and mitigate gaps in the program. The OIG concluded that lack of action by facility leaders contributed to these missed opportunities.VA concurred with the OIG’s 11 recommendations, including four addressed to the Under Secretary for Health related to granting specific positions access to patient safety program databases, reporting state licensing board actions to supervisors, patient safety program oversight, and publishing updated and relevant policies.The VISN Director also agreed to review patient safety event reports and the role of the Patient Safety/Risk Management Subcommittee in overseeing facility-level Patient Safety activity performance.The Facility Director concurred with recommendations for the timely completion and investigation of patient safety events, feedback to patient safety event reporters, reviews of events, and ensuring programmatic oversight and accountability, with documentation of discussion, review, and action.

This Management Advisory presents the results of meetings OIG employees conducted with EXIM employees assigned to 10 of the agency’s regional offices to increase their awareness of OIG’s role and obtain feedback on the role of the regional offices with respect to EXIM’s programs and operations.

Federal mineral lease operators are diverting natural gas to power electric generators for cryptomining operations without paying gas royalties.

For our final report on our evaluation of the U.S. Census Bureau’s (the Bureau’s) award and use of a cooperative agreement to participate in a joint statistical project with Research Triangle Institute (RTI), an independent nonprofit institution, our objective was to determine whether the cooperative agreement was properly authorized, executed, and administered in accordance with relevant laws and regulations. Specifically, we determined whether (1) the Bureau's award of the Ask U.S. Panel cooperative agreement was in accordance with applicable federal regulations and Bureau policies, and (2) the Bureau's administration of the agreement complied with terms and conditions established in it. We found that the Bureau’s use of a cooperative agreement was authorized by statute and the process for awarding the cooperative agreement followed the agency’s guidelines. However, the Bureau’s management and oversight of the cooperative agreement lacked transparency over key financial assistance award processes. Specifically, I. the Bureau lacked documentation to support the need for the Ask U.S. Panel and the decision to utilize a cooperative agreement; II. improper planning resulted in scope expansion; III. the Bureau reimbursed RTI without validating costs; and IV. the Bureau did not disclose its plans to terminate the cooperative agreement until after we completed our fieldwork.

Johnathan Pena, a medical marketer based in Los Angeles, California, was sentenced on February 27, 2023, to time served and three years’ probation for conspiracy to commit health care fraud and honest services mail fraud, as well as a violation of the Travel Act. Pena was also ordered to forfeit $134,336.78.Pena brokered kickbacks and bribe payments to doctors in exchange for their referrals of compounded medications, durable medical equipment, and other health care goods to certain providers. Specifically, our investigation found that Pena worked as a marketer for TYY Consulting, Inc., to provide medically unnecessary compounded drug prescriptions to Precise Compounding Pharmacy that were reimbursed by health care benefit programs, including Amtrak’s plan. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $22,000.