Federal Reports

The VA Office of Inspector General (OIG) Vet Center Inspection Program provides a focused evaluation of aspects of the quality of care delivered at vet centers. This report focuses on Continental district 4 zone 1 and four selected vet centers: Casper, Wyoming; Denver, Colorado; and El Paso and Midland in Texas. The inspection focused on six review areas: leadership and organizational risks; quality reviews; COVID-19 response; suicide prevention; consultation, supervision, and training; and environment of care.Generally, district leaders were knowledgeable about quality improvement principles and engaged in continuous improvement activities in response to VA All Employee Survey results. District 4 zone 1 Vet Center Service Customer Feedback survey results exceeded national scores in four of the six categories.The OIG conducted an analysis of vet center quality reviews required to ensure compliance with policy and procedures. The OIG made three recommendations for clinical and administrative quality reviews and one recommendation for critical incident quality reviews.The COVID-19 response review showed that while initially there were personal protective equipment shortages for staff, adequate supplies were reported at the time of inspection. Employees’ responses indicated that district leaders and vet center directors provided communication and guidance that helped with employee and client safety.The suicide prevention review included a zone-wide evaluation of electronic client records, and a focused review of four selected vet centers. The OIG issued eight recommendations—seven specific to electronic client records and one for selected vet centers’ suicide prevention and intervention processes.The consultation, supervision, and training review evaluated the four vet centers. The OIG identified concerns with external clinical consultation, supervision, and training, and issued five recommendations.The environment of care review evaluated the four vet centers. The OIG made three recommendations.The OIG issued a total of 20 recommendations for improvement to the District Director.

The Federal Risk and Authorization Management Program (FedRAMP) standardizes security and risk assessments for cloud technologies for federal agencies, including VA. In April 2019, the VA Office of Inspector General (OIG) received allegations that VA’s Office of Information and Technology’s (OIT’s) Project Special Forces (PSF) was not following FedRAMP policies or VA policy for deploying software-as-a-service (SaaS) applications. The OIG found that OIT granted security authorizations for applications that were not authorized by FedRAMP. Eight of the nine applications cited by the complainant were in use on the VA network—some without FedRAMP or VA authorization. Another three applications were approved to operate on VA’s network without FedRAMP authorization. The OIG did not substantiate that PSF-developed applications were improperly managed outside the VA Enterprise Cloud group. However, PSF did not follow VA security requirements in developing interfaces that allow third parties to “plug into” the VA to send and retrieve data. OIT personnel stated that there was no formal OIT authorization process until April 2019. After that date, the review team did not find instances of VA-authorized applications without FedRAMP authorization. OIT staff also misunderstood the FedRAMP authorization requirements for SaaS applications containing data classified as less sensitive.Failure to comply with FedRAMP standards increases the risk that VA and veterans’ data could be compromised. The OIG made four recommendations to the acting chief information officer (1) to determine whether to prevent use of the unauthorized SaaS applications and (2) whether the reviewed applications should be authorized or reported to the Federal Chief Information Officer. The remaining recommendations were (3) to implement alerts for interface-related abuse and (4) to either use application programming interfaces that transmit sensitive information and requirements for cross-origin resource sharing or seek exceptions to the standards. VA concurred with all recommendations.

While conducting fieldwork for our International Mail Operations and Performance Data project, we found significant operational delays of international outbound (export) packages. Operations were significantly challenged at the Postal Service’s five ISCs due to a large number of export packages identified as having insufficient AED. Postal Service data showed nearly 2.9 million pieces with missing AED between January and August 2021. We also found significant processing delays of some export packages identified with insufficient AED.

The OIG conducted a performance audit to determine whether the FTC’s contracting officer’s representative (COR) program is operating in compliance with federal requirements and FTC policies and procedures.

For our final report on the evaluation of the United States Patent and Trademark Office’s (USPTO’s) patent examination process, our objectives were to (I) assess whether patents are examined in compliance with applicable statutes, regulations, and case law; (2) identify deficiencies within the examination process impacting the quality of patents granted; and (3) identify areas for improvement within the examination process to increase its effectiveness and efficiency. We contracted with The MITRE Corporation (MITRE)—an independent firm—to perform this evaluation. Our office oversaw the progress of this evaluation to ensure that MITRE performed the evaluation in accordance with the Council of the Inspectors General on Integrity and Efficiency’s Quality Standards for Inspection and Evaluation (December 2020) and contract terms. However, MITRE is solely responsible for the attached report and conclusions expressed in it.

HHS-OIG'S Semiannual Report to Congress describes OIG's work identifying significant risks, problems, abuses, deficiencies, remedies, and investigative outcomes relating to the administration of HHS programs and operations that were disclosed during the semiannual reporting period April 1, 2021, through September 30, 2021.