Federal Reports

RMA was engaged by the U.S. AbilityOne Commission Office of Inspector General (OIG) to conduct the performance audit and issue its report. The objectives of the audit were to assess 1) the completeness, accuracy, timeliness, and quality of the Q2 FY 2021 financial and award data submitted by the Commission for publication on USASpending.gov, and 2) the Commission’s implementation and use of the government-wide financial data standards established by the Office of Management and Budget (OMB) and the U.S. Treasury (Treasury). To answer the audit objectives, the RMA team obtained and identified information about applicable records from Commission and 3rd party data systems. RMA then sampled, reviewed, and reconciled Q2 FY 2021 financial and award data submitted by the Commission for publication on USASpending.gov. The team also assessed 1) controls in place for the extraction of data from source systems and for the reporting of data to the Treasury, 2) the completeness, accuracy, timeliness, quality of the financial as well as award data sampled, and 3) the Commission’s implementation and use of the 59 data elements and standards established by OMB and Treasury.

In this white paper, the OIG sought to identify opportunities and challenges in adopting electric delivery vehicles. We assessed the suitability of using electric vehicles as delivery vehicles and analyzed the potential long-term cost savings of a new electric delivery vehicle compared to a new gas-powered vehicle. We also benchmarked the electric vehicle experiences of other federal agencies, foreign posts, and companies in the logistics and shipping sector. We identified several clear benefits of adopting electric vehicles into the postal delivery fleet, including improved sustainability and environmental impacts. Our research confirms that electric vehicle technology is generally capable of meeting the Postal Service’s needs.

This report details the OIG’s healthcare inspection to assess a range of allegations regarding medication management deficiencies and potential patient safety issues associated with implementation of the new electronic health record (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington.The OIG found that the new EHR implementation was deficient in numerous areas affecting medication management, including (1) data migration issues leading to inaccurate contact information and medication lists; (2) medication order processes erroneously discontinuing certain medications, permitting registered nurses to enter orders without authorization, and failing to notify providers of important prescribing information; and (3) medication reconciliation processes being impeded by incomplete medication lists that led to staff developing time-consuming workarounds, which increased risks of errors.Many of the medication management deficiencies remained unresolved during the OIG’s inspection from January to early June 2021. Although the OIG did not identify any associated patient deaths during this inspection, deployment of the new EHR without resolution of deficiencies may present risks to patient safety and affect providers’ treatment decisions.Findings can be found in two companion reports related to clinical care coordination issues after going live, concerns identified with the process for addressing “tickets” for resolving problems, and factors that contributed to deficiencies.The OIG made two recommendations to the Deputy Secretary: Ensure that substantiated and unresolved allegations are reviewed and addressed, and notify the OIG of any other medication management issues identified after the healthcare inspection. VA concurred with the first recommendation but not with the second, stating the recommendation creates a continuous reporting requirement to the OIG that prevents its closure. The OIG reminded the VA of its duty to provide this information and will close the recommendation when VA demonstrates an effective and sustainable process to identify and address patient safety issues.