Federal Reports

The Office of the Inspector General conducted a review of the Allen Integrated Site (Allen) to identify factors that could impact Allen’s organizational effectiveness. During the course of our evaluation, we identified positive behavioral factors, including relationships with team members and business units outside Allen; however, we also identified behavioral concerns with two managers. In addition, we identified operational factors needing improvement related to (1) perceptions of ineffective work management, (2) fire alarm system repairs, and (3) site security and access concerns. Management is addressing some of these concerns by implementing a Gas Operations’ initiative to address work management, overseeing fire alarm system repairs, and submitting documentation to upgrade site security.

This report presents the results of our self-initiated audit of the U.S. Postal Service’s Mail Transport Equipment (MTE) Program (Project Number 21-229). Our objective was to assess Postal Service management of the MTE program. See Appendix A for additional information about this audit.MTE consists of containers (including sacks, pouches, trays, wheeled containers, pallets, etc.) used to contain mail during processing and while transporting it between postal facilities, delivery units, and mailers.The Postal Service purchases and distributes MTE to transport mail. The use of MTE is provided as a courtesy to convey mail to and from facilities and mailers and it may not be retained or used for unauthorized purposes. Additionally, to reduce processing costs, all MTE must be properly containerized or finalized as Postal Prepared Finished Goods (PPFG) and must have a Mail Transport Equipment Labeler (MTEL) placard affixed prior to it being returned to the Mail Transport Equipment Service Center (MTESC).The Postal Service’s MTESC network is comprised of 14 contractor-operated centers that are responsible for processing, repairing, storing, and distributing MTE in a timely and efficient manner. The Mail Transport Equipment Support System (MTESS) supports MTESCs and processes orders for facilities and large mailers.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to a primary care provider’s delivery of hypertension treatment and post-stroke care, nursing staff communication and documentation, and facility telephone communication processes at the Amarillo VA Healthcare System (system) in Texas. The OIG was unable to determine whether delays in treatment for hypertension and headaches caused the patient’s stroke and did not find primary care-related treatment failures in the weeks leading up to the stroke. However, when the patient presented to the clinic with stroke-like symptoms in early 2021, the provider and clinic nurse failed to ensure the patient received urgent medical attention. The delay in evaluation and treatment may have resulted in a more difficult recovery for the patient.The OIG did not substantiate allegations regarding a failure to order cardiology and neurology consults, that a licensed vocational nurse diagnosed the cause of the patient’s headaches, or that secure messaging was the only way the patient could communicate with the primary care team. The OIG was unable to determine whether nurses’ communications were dismissive and condescending.The OIG identified multiple system leaders’ failure to assess and follow through on the provider’s ongoing quality of care deficits. These failures allowed the provider to continue practicing substandard medicine, and as a result, patients experienced adverse outcomes. The provider has been functioning in an administrative capacity without direct patient care duties since spring 2021.The OIG made one recommendation to the Veterans Integrated Service Network Director to assess system leaders’ actions related to professional practice evaluations, institutional disclosure, and staff training.The OIG made five recommendations to the System Director related to vital sign protocols, clinical practice evaluation of a nurse, respectful communications, critical view alerts and other quality of care reviews, and communication and documentation requirements.

This management alert presents issues identified during our Review of National Change of Address and Moversguide Applications audit (Project Number: 21 146). Our objective is to notify U.S. Postal Service management of risks associated with ineffective identify verification controls on the Moversguide application. See Appendix A for additional information about this alert.

This investigation was initiated based on a Highway Contract Route driver for the Postal Service who alleged he transported completed mail-in ballots across state lines from Bethpage, NY, to Lancaster, PA, on October 21, 2020.