Federal Reports

The VA Office of Inspector General (OIG) assessed allegations at the VA Greater Los Angeles Health Care System in California (facility) that community living center (CLC) nursing staff failed to (i) assess a resident who was complaining of pain; (ii) properly document assessments, reassessments, treatments, or interventions; and (iii) follow and implement a provider’s order related to transferring the resident to a higher level of care. The OIG also identified concerns associated with an institutional disclosure and inadequate care coordination.The OIG found that the day charge nurse’s assessment was delayed and incomplete, and the day charge nurse failed to properly document the resident’s reassessments, treatments, and interventions. However, the OIG did not substantiate that other individual nursing staff members involved with the resident’s care failed to properly document the resident’s care. The OIG substantiated that nursing staff failed to document and carry out a telephone order to transfer the resident to the Emergency Department but was unable to determine if this impacted the patient’s outcome. The OIG determined that following the resident’s death, facility staff failed to conduct a comprehensive review of events leading up to and contributing to the resident’s death and, due to a lack of coordination of care at the time of discharge from the inpatient unit, the resident did not have the needed equipment upon admission to the CLC.The OIG made 10 recommendations to the Facility Director regarding confirmation of CLC nursing staff’s knowledge of policies related to nursing practices, documentation, pain assessments, verbal orders, Joint Patient Safety Reports, administrative reviews, and quality assurance reviews; a review of hand-off communications; the need for peer reviews specific to the resident’s care and CLC admission processes related to respiratory therapy equipment; completion of action items identified in the Corrective Action Plan and an institutional disclosure.

BackgroundThe U.S. Postal Service has essential business relationships with its suppliers to perform many functions that closely support Postal Service operations. The Postal Service aims to build and maintain these relationships based on the potential impact suppliers’ performance has on the Postal Service’s operational and financial position. From fiscal years (FY) 2019 to 2021, the Postal Service’s managed spend for goods and services was about $17 billion on contracts distributed throughout ten Supply Management Category Management Centers and four Portfolios. What We DidOur objective was to determine if the Postal Service evaluates and manages risks associated with suppliers’ performance to fulfill contractual requirements successfully. We reviewed a judgmental sample of 94 Postal Service suppliers with a managed spend of $1 million and above per contract from FYs 2019 to 2021.

We audited the U.S. Department of Housing and Urban Development’s (HUD) Emergency Solutions Grants Coronavirus Aid, Relief, and Economic Security Act (CARES Act) (ESG-CV) program. Our audit objective was to determine what challenges ESG-CV grant recipients faced in implementing the program and using grant funds. We used a survey questionnaire to gather feedback and insight directly from the 362 recipients of ESG-CV grants. At the time we initiated this audit in July 2021, ESG-CV grant recipients had spent $563,178,336 of available $3.96 billion grant funds. We performed this audit to assist HUD’s Office of Community Planning and Development in identifying opportunities to improve the timeliness and use of ESG-CV grant funds.Our survey questionnaire of the ESG-CV grant recipients found that they faced challenges in implementing the program and using grant funds. The grant recipients needed an extension beyond the spending deadline of September 30, 2022, to use a majority or all of their ESG-CV funds. HUD subsequently extended the spending deadline to help address this issue. The top challenges identified by the grant recipients included staff capacity and coordinating with other sources of pandemic related funding. In addition, a majority of the grant recipients that provided ESG-CV funds to subrecipients stated that the pandemic impacted their ability to effectively monitor their ESG-CV subrecipients. As a result, while HUD has taken action to help address the spending deadline concerns, the grantees’ challenges with capacity, multiple funding sources, and monitoring their subgrantees may increase the risk of misuse of the funds. HUD can use the results of our survey questionnaire to potentially improve the continued implementation of the ESG-CV program and to inform its risk assessment of ESG-CV grantees.We recommend that the Principal Deputy Assistant Secretary for Community Planning and Development consider including grant recipients’ challenges with capacity, multiple sources of funding, and subgrantee monitoring as part of CPD’s risk assessments.

An Amtrak service attendant based in Seattle resigned from his position on August 17, 2022, as a result of our investigation into his alleged abuse of COVID-19 Leave. Our investigation found that the employee was placed on COVID-19 Leave on July 8, 2022, a type of leave that is granted for a 5-day period. However, the employee failed to produce proof of a COVID-19 diagnosis, as required by the company, and remained away from work for 30 days. Our investigation found that the employee was working as a travel advisor for a travel agency at the time of his resignation.

What We Looked AtThis report presents the results of our quality control review (QCR) of an attestation examination of the Department of Transportation's (DOT) Enterprise Services Center (ESC) controls. ESC provides financial management services to DOT and other agencies and operates under the direction of DOT's Chief Financial Officer. The Office of Management and Budget requires ESC, as a service organization, to either provide its user organizations with independent audit reports on the design and effectiveness of its internal controls, or allow user auditors to perform tests of its controls.We contracted with KPMG LLP to conduct this examination subject to our oversight. The objectives of the review were to determine whether (1) management's description of ESC's systems is fairly presented, (2) ESC's controls are suitably designed, and (3) ESC's controls are operating effectively throughout the period of October 1, 2021, through June 30, 2022. We performed a QCR on KPMG's report and related documentation.What We FoundOur QCR disclosed no instances in which KPMG did not comply, in all material respects, with generally accepted Government auditing standards.Our RecommendationsKPMG made no recommendations.The quality control review and attachments have been marked as For Official Use Only to protect sensitive information exempt from public disclosure under the Freedom of Information Act, 5 U.S.C. § 552. To receive a copy of the report, please contact our Freedom of Information Act Office.