Federal Reports

NASA’s Ames Research Center—located in California’s Silicon Valley—is utilizing leases in an attempt to transform the Center into a shared-use research and development campus by collaborating with private industry, academia, government, and nonprofit organizations. In this audit, we assessed the effectiveness of Ames’ lease management practices.

In August 2020, the Veterans Health Administration’s (VHA) Office of Connected Care introduced a “digital divide” consult process where patients can receive a video-capable device (iPad) after obtaining a referral and a socioeconomic assessment. The VA Office of Inspector General (OIG) reviewed the efficiency and effectiveness of the process.The review found the program successfully distributed devices to patients but identified gaps in oversight and guidance. VHA issued devices to about 41,000 patients during the first three quarters of fiscal year 2021. The OIG found 51 percent did not use the devices to complete a video appointment.The OIG reviewed VHA’s data and found that 3,119 patients received multiple devices. A November 2021 assessment of the data also showed nearly 8,300 unused devices still did not have VA Video Connect activity and were not retrieved to make them available to other patients. The value of the 8,300 devices was about $6.3 million, and they cost VHA about $78,000 in additional cellular data fees.Moreover, as of December 2021, VHA paid about $8.1 million for the purchase of 9,720 devices, although a backlog of about 14,800 returned devices was pending refurbishment to be available for redistribution. Overall, the OIG determined VHA could have made better use of about $14.5 million in program funds with better device monitoring, retrieval controls, and oversight.The OIG made 10 recommendations to the under secretary for health, including alerting the requesting clinic that a patient can be scheduled, adding procedures on duplicate devices, designating responsible officials to monitor for appointment activity and connected device use, clearly defining lead oversight responsibilities, and establishing an automated report of devices not being used for video appointments. Lastly, VHA should enhance tracking of device packages, implement more detailed refurbishment reporting, and use such data in new device purchases.

The VA Office of Inspector General (OIG) assessed an allegation at the Michael E. DeBakey VA Medical Center (facility) that community living center (CLC) staff delayed life-sustaining treatment for a patient (Patient A) who experienced cardiac arrest and died. The OIG also reviewed an allegation regarding a second patient (Patient B) who had resuscitation initiated, despite a do not resuscitate (DNR) order in the electronic health record (EHR).The OIG substantiated that a CLC nurse delayed initiation of resuscitation efforts for Patient A. The OIG found that the CLC nurse identified Patient’s A’s code status as DNR after checking a report sheet and seeing a DNR armband. However, Patient A was a full code status, as reflected in the EHR. The nurse did not review the EHR, causing delayed resuscitation efforts. The OIG substantiated that facility inpatient nursing staff attempted to resuscitate Patient B who had a DNR order. Inpatient nursing staff relied on the absence of a DNR armband to indicate Patient B’s code status and relayed the incorrect code status to the code blue team during the patient’s cardiac arrest. The code blue team performed resuscitative efforts until a medical resident reviewed the EHR and identified Patient B’s status as DNR. The OIG identified concerns related to the use of DNR armbands and the suspension of DNR orders in the operating room.The OIG made one recommendation to the Under Secretary for Health regarding reviewing DNR processes and five recommendations to the Facility Director related to staff’s EHR verification of life-sustaining treatment orders and patients’ code statuses, evaluation of corrective actions from management reviews, location of life-sustaining treatment orders within the EHR, modifications to patients’ life-sustaining treatment orders during surgical procedures, and staff’s review of patients’ code statuses upon patients’ return to facility units from surgical procedures.

The U.S. Postal Inspection Service is responsible for ensuring the safety and security of postal employees, postal facilities, and the mail. The Postal Inspection Service has contracted with Prosegur Services Group Inc. to provide personnel, such as dispatchers, at the National Law Enforcement Communication Centers (NLECC) and security guards at postal facilities in approximately 57 locations nationwide.Our objective was to assess the compliance of the Postal Inspection Service’s Prosegur contract with applicable policies and procedures during fiscal year 2021. We reviewed contract documentation and policies, sampled personnel and invoices from the two NLECC facilities and six sites with security guards, and interviewed Postal Service and Prosegur officials.