Federal Reports

The Office of Inspector General (OIG) Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Service Network (VISN) 23 and its oversight of the quality of care delivered in community-based outpatient clinics (CBOCs) and through its community care referrals to non-VA providers. Although it is difficult to measure the value of well-delivered and coordinated care between VA and non-VA providers, the findings in this report may help VISN leaders identify vulnerable areas of community care that, if properly addressed, should improve healthcare quality for veterans.The OIG reviewed care coordination for congestive heart failure management; primary care and mental health (diagnostic evaluations following positive screenings for depression or alcohol misuse); quality of care (home dialysis care); and women’s health (mammography care and communication of results).The OIG issued three recommendations for improvement in two areas:(1) Quality of Care• Completing initial and annual home visits for patients accepted into the VISN 23 home dialysis program• Monitoring quality of home dialysis contracted clinical services(2) Women’s Health• Receiving written results from community providers within 30 days of the procedure

We investigated allegations that former DOI Secretary David Bernhardt violated the Lobbying Disclosure Act before joining the DOI as Deputy Secretary.

In this semiannual period, our audit, evaluation, and investigative activities identified more than $9.3 million in questioned costs, funds put to better use, recoveries, waste, and opportunities for TVA to improve its programs and operations.

The Office of Enterprise Assessments implements an Independent Oversight Program to provide Department of Energy line management, Congress, and other stakeholders with an independent evaluation of the effectiveness of Department policy and line management performance in safety, security, and other critical areas. The Office of Environment, Safety and Health Assessments (EA-30), a subordinate office within the Office of Enterprise Assessments, conducts assessments to provide information on the effectiveness and performance of Department programs in protecting workers, the public, and the environment from hazards.We initiated this audit to determine whether the Department is addressing findings and deficiencies identified by EA-30. Our review found that the Department did not always fully address findings and deficiencies identified by EA-30.These issues occurred, in part, because the sites we reviewed did not always provide sufficient oversight pertaining to EA-30 findings and deficiencies, including inconsistent oversight of the issues management processes. In addition, EA-30’s processes presented opportunities for improvement, including tracking findings and deficiencies. As a result of this audit, EA-30 has begun to take steps to address these issues.Department programs may be at risk of unaddressed weaknesses in protecting workers, the public, and the environment from hazards. Effective oversight is an integral part of the Department’s responsibility to provide assurance of its safety and security posture to its leadership, its workers, and the public.To address the issues identified in this report, we have made six recommendations that, if fully implemented, should help ensure that findings and deficiencies are addressed, and effective corrective actions are implemented and documented.