Federal Reports

This insights report provides a contextual understanding of the cross-cutting challenges states faced within their unemployment insurance (UI) programs and highlights the substantial work that has been done by State Auditors to ensure their states’ UI programs are functioning effectively. This report examines four common insights across 16 State Auditor Offices: (1) UI workloads surged for states; (2) the claims surge exploited internal control weaknesses; (3) uncommon and varying fraud schemes began to occur as the amount of federal funding expanded; and (4) state workforce agencies experienced information technology system challenges

The Veterans Health Administration (VHA) uses contractors to provide oxygen services to veterans who need respiratory care in their homes. The OIG examined whether VHA’s oversight of the home oxygen program ensured (1) patients received reevaluation of their need for home oxygen and home visits were conducted as required, and (2) contractor performance was monitored and invoicing and payments were checked for accuracy.The OIG found that prescribing providers did not always reevaluate home oxygen patients timely and medical facility staff did not always conduct home visits for the required number of patients. As a result, VHA lacked an essential component for ensuring patient safety and high quality vendor service. In addition, contract monitoring by contracting officers and their representatives was inadequate, caused by a lack of oversight and differing interpretations of guidance. Payments, however, were generally processed accurately.During the audit, the team also found that VHA paid for services using expired contracts for two facilities: the Charlie Norwood VA Medical Center in Augusta, Georgia, and the Ralph H. Johnson VA Medical Center in Charleston, South Carolina.The OIG made six recommendations to the under secretary for health. These included implementing guidance for managing home oxygen consults, clarifying reevaluation timelines, updating responsibilities for home visit oversight, and requiring network contracting office oversight of contracting officers to ensure completion of evaluation and quality monitoring elements and to properly designate contracting officer’s representatives. The OIG also recommended clearly communicating the processes staff should use to achieve the contract monitoring requirements in the Federal Acquisition Regulation. Regarding the expired contracts, the OIG recommended reviewing the identified orders for home oxygen services that were paid without an awarded contract and submitting a request for ratification for any unauthorized commitments to VHA’s head of contracting activity.

The OIG assessed the oversight and stewardship of funds and identified opportunities for cost efficiency at the Marion VA Healthcare System in Illinois. The review focused on four areas:1. Use of the Medical/Surgical Prime Vendor-Next Generation program. The program is a collection of contracts that streamlines purchasing and distribution for certain supplies. The team found that the system was unable to fully achieve the program’s cost savings, in part because some items were in short supply during the pandemic or on back order with the prime vendor.2. Purchase card use. The team did not find staff were improperly splitting purchases to stay below the card purchase limits. Moreover, system staff properly maintained supporting documentation for the sampled transactions and considered contracts instead of purchase cards when appropriate. However, the purchase card program coordinator did not always perform required quarterly audits, and oversight on training for cardholders could be strengthened.3. Open obligations. The team found that the system’s fiscal staff did not always review open obligations for goods and services to determine if they were still valid and necessary. This leaves the system vulnerable to the risk that those funds will be not used in the year they were appropriated, as required.4. Pharmacy operations and cost-savings efforts. The review team found the system had a significant gap between actual and expected drug costs when compared with like facilities. However, it achieved a higher inventory turnover rate than VA’s target rate, which helps reduce the cost of storing inventory.The OIG made eight recommendations for improving cost efficiency. The number of recommendations should not be used, however, to gauge the system’s overall financial health. The intent is for system leaders to use these recommendations as a road map for improvement in the areas reviewed.

The Office of the Inspector General conducted a review of Browns Ferry Nuclear Plant (BFN) Chemistry to identify factors that could impact BFN Chemistry’s organizational effectiveness. During the course of our evaluation, we identified behaviors that had a positive impact on BFN Chemistry, including positive relationships between team members and most management. However, we also identified a minimal behavioral risk related to communication with first-line management. In addition, we identified minimal risks to operations that, if unaddressed, could hinder BFN Chemistry’s effectiveness. These risks related to nonfunctioning equipment and perceptions of inadequate staffing.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to assess an allegation that the facility failed to diagnose and treat a patient’s cancer. The OIG identified concerns about potential deficiencies in lung cancer screening, prostate cancer surveillance, consult delay, documentation, and the facility’s response to family complaints.The OIG substantiated that providers failed to make a cancer diagnosis and treat the patient’s cancer. Providers did not take steps that would have allowed them to make a diagnosis, including ordering screening tests. In fall 2020, the patient was found to have left lung primary lung cancer with metastasis to brain, liver, and other areas. The patient died three weeks later.The patient had known lung cancer risk factors that warranted annual screening. The OIG did not find evidence beyond 2013 that pulmonology staff followed up, or that after 2017, primary care providers ensured completion of annual screening. Additionally, the OIG determined that primary care providers did not follow up after a radiology finding that a renal nodule had increased in size. The OIG found that after summer 2016, the patient did not have annual testing completed to check for prostate cancer recurrence. The OIG determined that one primary care provider delayed ordering an oncology consult for 25 days, copied and pasted documentation, and did not document an assessment of the patient’s lung nodules, as required. The OIG found that facility staff documented resolution of a family member’s complaint despite not contacting the family.The OIG made five recommendations to the Facility Director related to evaluation of lung cancer screening and follow-up care; follow-up for abnormal radiology findings; surveillance for patients who have undergone prostatectomy; copy and paste practices and documentation; and review of complaint reporting and responding.

The Baltimore Processing and Distribution Center (P&DC) is in the Chesapeake Division of the Eastern processing region and that facility processes letters, flats, and packages. From August 1, 2020, to July 31, 2021, the Baltimore P&DC processed about 1.67 billion mailpieces compared to about 1.74 billion mailpieces during the same period last year — a decrease of about 70 million mailpieces (4 percent). However, during that same period, workhours and overtime at the facility increased by 14.6 and 43.5 percent, respectively.Recently, the OIG audited nine Baltimore delivery units as part of a congressional request to evaluate mail delivery and customer service operations on selected routes. The objective of this separate but related self-initiated audit was to evaluate the efficiency of plant operations at the Baltimore, MD, P&DC. This audit was completed to identify mail processing issues at the Baltimore P&DC that could affect delivery units served by this P&DC.

This final report provides the results of our evaluation of the U.S. Department of Commerce’s (the Department’s) processes for handling hotline complaints referred by the Office of Inspector General (OIG). The objective of our evaluation was to review the Department’s processes for responding to hotline complaint referrals where OIG requests that the Department conduct an inquiry and provide a response detailing its results (also known as H referrals). Overall, we found that the Department lacked an effective process and internal controls over its hotline \ referrals. This report includes recommendations for the Department to implement internal controls for addressing H referrals efficiently and effectively. See appendix A for specific details on our objective, scope, and methodology.