Federal Reports

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.

Objective: To determine whether the Social Security Administration (SSA) took appropriate follow-up actions when spouses and widow(er)s reported they would be entitled to a non-covered pension in the future.

Alain Galette, a resident of Miami, pleaded guilty in U.S. District Court, Southern District of Florida, to one count of wire fraud on August 4, 2022, in relation to his application for a Payroll Program Protection (PPP) loan and in obtaining an Economic Injury Disaster Loan (EIDL) in the amount of $149,900. The PPP loan was in the amount of $163,577 but was denied. Our investigation found that Galette used an invalid social security number and included other false information on the PPP and EIDL applications. Upon receipt of the EIDL funds, Galette did not use the money for authorized purposes.

Identity, credential, and access management (ICAM) is a set of tools, policies, and systems used to ensure the right individual has access to the right resource, at the right time, for the right reason in support of federal business objectives. In February 2021, the VA Office of Inspector General (OIG) received a hotline complaint claiming the Office of the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness and the Office of Information and Technology have not agreed since 2016 on roles and responsibilities for VA’s ICAM program. This has contributed to VA not being able to effectively comply with Office of Management and Budget (OMB) policy. The OIG reviewed to determine whether VA is effectively governing its ICAM program as required.The OIG found VA did not effectively manage and coordinate its ICAM program because it did not meet three of the four OMB governance requirements. Specifically, VA did not effectively assign roles and responsibilities, implement a single comprehensive ICAM policy, meet goals established in its technology solutions roadmap for fiscal years 2020 and 2021, or implement updated digital identity risk management requirements.These issues occurred primarily because leaders of the different offices performing VA’s ICAM functions have not agreed on how it should be governed. Without proper governance, VA risks both restricting information from users who need it to perform their job functions and leaving information vulnerable to improper use.The OIG recommended the VA deputy secretary designate roles and responsibilities for all program offices involved in the ICAM process and ensure appropriate oversight and coordination. The OIG also made recommendations to the assistant secretary for information and technology and to the assistant secretary for human resources and administration/operations, security, and preparedness.

The VA Office of Inspector General (OIG) conducted this review to determine whether the Veterans Benefits Administration (VBA) accurately adjusted compensation and pension benefit payments for fugitive felons as mandated by law. If VBA does not adjust payments, veterans who are fugitive felons will continue to receive benefits during periods of ineligibility.Routinely, the OIG provides VBA with a list of individuals with felony arrest warrants gathered from federal and local law enforcement agencies. After the passage of the Veterans Education and Benefits Expansion Act of 2001, VBA interpreted the law to presume that all veterans for whom a felony arrest warrant had been issued were fugitives in a flight status.In April 2012, VBA instructed regional offices to postpone making decisions on fugitive felon cases while it prepared new guidance. During 2012 and 2013, VBA did not process fugitive felon cases. In June 2014, VBA updated its definition of a fugitive felon to include only referrals indicating escape, flight, or violation of the conditions of probation or parole. Although VBA then resumed adjusting payments, it did not review the unprocessed 2012 and 2013 cases.In addition, due to inadequate monitoring, VBA did not process about 46 percent of cases referred by the OIG in 2019 and 2020. Finally, the team found VBA’s notification letters to veterans providing notice of the proposed action and right to a hearing did not always provide the required information. Most commonly, VBA failed to include the reason for the issuance of the arrest warrant.VBA concurred with the OIG’s three recommendations to (1) improve monitoring procedures, (2) review unprocessed felony referrals, and (3) update fugitive felon letters with required information. Based on the information provided by VBA on the actions taken to address these recommendations, the OIG considers recommendation 2 closed.