Federal Reports

The VA Office of Inspector General (OIG) conducts information technology (IT) inspections to assess whether VA facilities are meeting federal security requirements. They are typically conducted at selected facilities that have not been assessed in the sample for the annual audit required by the Federal Information Security Modernization Act of 2014 (FISMA) or at facilities that previously performed poorly. The OIG selected the Dallas Consolidated Mail Outpatient Pharmacy (CMOP) because it had not been previously visited as part of the annual FISMA audit.The OIG inspections are focused on four security control areas that apply to local facilities and have been selected based on their level of risk: configuration management controls, contingency planning controls, security management controls, and access controls. The OIG found deficiencies in configuration management and access controls at the Dallas CMOP, but none in contingency planning or security management controls.Without effective configuration management, users do not have adequate assurance that the system and network will perform as intended and to the extent needed to support the CMOP’s missions. The access control deficiencies create risks of unauthorized access to critical network resources, inability to respond effectively to incidents, loss of personally identifiable information, or loss of life.The OIG made 10 recommendations to the Dallas CMOP director aimed at fixing the control deficiencies. The assistant secretary for information and technology provided comments for the Dallas CMOP. The assistant secretary concurred with nine recommendations and did not concur with one recommendation. The OIG disagrees with the nonconcurrence.

The Office of the Inspector General for the Nuclear Regulatory Commission and the Defense Nuclear Facilities Safety Board presents its Semiannual Report to Congress. This report highlights the work the OIG has completed from October 1, 2021, to March 31, 2022.

The VA Office of Inspector General (OIG) conducted an inspection to review the care of an unresponsive patient by Emergency Department staff and the subsequent response of leaders at the Malcom Randall VA Medical Center (facility), after the patient’s death at the University of Florida Health Shands Hospital (Shands).The OIG determined that facility Emergency Department nurses failed to provide emergency care to an unresponsive patient who arrived by ambulance. Despite emergency medical services (EMS) personnel having relayed, while en route to the facility, the criticality of the patient’s condition and the limited patient identifying information available, Emergency Department nurses and an Administrative Officer of the Day wasted critical time concentrating efforts on whether the patient was a veteran (which the patient was, but not so identified by the nurses) versus patient care. As a result, EMS personnel reloaded the patient into the ambulance for transport to Shands.The Emergency Department nurses disregarded EMS personnel’s patient status report, failed to recognize the patient’s emergency medical condition, and inaccurately assessed the patient’s condition. The OIG identified deficiencies in nursing competencies and concerns regarding the replication of competency assessments.The OIG learned that the facility had prior instances of Veterans Health Administration Emergency Medical Treatment and Labor Act (EMTALA)-related policy violations in 2019, resulting in Emergency Department staff being required to complete EMTALA-related training. The OIG found the actions implemented by facility leaders to address concerns were not effective in preventing the occurrence of additional patient incidents, and delays in the provision of emergency care to patients continued.The OIG made one recommendation to the Veterans Integrated Service Network Director regarding consideration of administrative action and reporting to state licensing board(s). The OIG made four recommendations to the Facility Director related to the prioritization of emergency patient care and nursing competencies.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 2: New York/New Jersey VA Health Care Network in Bronx, New York, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The VISN had a stable leadership team, with the Quality Management Officer and Chief, Human Resources Officer permanently assigned prior to the integration of VISNs 2 and 3 in 2015. Selected employee satisfaction survey scores indicated that some VISN leaders had opportunities to improve employee perceptions of servant leadership, respect, discrimination, and psychological safety. Inpatient experience survey scores were lower than VHA national averages but outpatient ratings were higher. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks, with wait times over 20 days at one medical center and clinical vacancies in certain specialties. Opportunities existed to improve executive leadership oversight of facility-level oversight of quality, safety, and value; care coordination; and high-risk processes.The OIG issued four recommendations for improvement in three areas:(1) Medical Staff Credentialing• Physician credentials review process(2) Environment of Care• Annual reviews(3) Women’s Health• Lead women veterans program manager appointment• Annual site visits

This interim report presents the results of our self-initiatedaudit of the efficiency of selected processes at the WyliePost Office in Wylie, TX (Project Number 22-066). This auditwas designed to provide U.S. Postal Service managementwith timely information on potential financial control risksat Postal Service locations. The Wylie Post Office is in theTexas 1 District of the Southern Area. We judgmentallyselected the Wylie Post Office for our audit.Our objective was to review cash and stamp inventories,daily reporting activities, clock ring errors, and employeeseparations processing at the Wylie, TX Post Office.To accomplish our objective, we reviewed data regardinginventories, daily reporting activities, clock ring errors,and employee separations to identify at risk transactions.1We conducted physical counts of all cash, stamp, andmoney order inventories, reviewed stamp transfers, andevaluated selected internal controls. We also observeddaily closing procedures, traced selected transactions tosource documentation, and interviewed unit personnel. Wedetermined the cause of clock ring errors and the stepstaken to resolve them. We also reviewed compliance withprocedures for separated employees, including timelysuspending system access and collecting and protectingaccountable property. We discussed our observations andconclusions with management on May 9, 2022, and includedtheir comments where appropriate.1

An Amtrak operation supervisor based in Miami resigned from the company on May 31, 2022, after he failed to respond to company letters advising him to report as available for duty. Prior to his resignation, we conducted an investigation and found that he violated company policies by engaging in self-employment as an independent realtor while on a medical leave of absence and while receiving short-term disability benefits. The company issued the employee a Notice of Investigation following the issuance of our investigative report and he failed to report to work.