Federal Reports

We found that a senior political employee’s communications with a former employer did not comply with paragraph 6 of the Federal ethics pledge.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 1 and 8 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of information given the quickly changing landscape as infection rates and demands on facilities continually shift. Findings of inspected medical facilities are grouped by VISN, which are regional offices that provide oversight of medical centers in their area.This report, the third in a series, describes findings on COVID-19 practices from healthcare inspections performed at facilities within VISNs 1 and 8 during the second quarter of fiscal year 2021 (January 1 through March 31, 2021). It also provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of July 2021. Interviews and survey results provide additional context on lessons learned and perceptions of both preparedness and response. This report also provides data that illustrates the tremendous COVID-19-related demands on VA healthcare services. It describes leader and staff experiences, assessments, shared sentiments, and best practices to help improve operations and clinical care during public health crises.At the time of the inspections, the Veterans Health Administration and VISNs were in the midst of VA’s third pandemic peak, which was longer and involved more patients than the previous peaks, and had valuable information to share about their experiences to date.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 1: VA New England Healthcare System in Bedford, Massachusetts, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.Most of the VISN’s executive leadership team had worked together since 2018; however, the Chief Medical Officer had served in an acting capacity since October 2020. Employee satisfaction survey scores indicated that leaders were engaged and promoted a culture of safety where employees felt safe bringing forward issues and concerns. Patient experience survey scores were higher than VHA averages. The OIG’s review of access metrics and clinical vacancies identified potential organizational risks at select facilities, with wait times over 20 days and clinical vacancies in certain specialties.The OIG issued five recommendations for improvement in three areas:(1) Medical Staff Credentialing• Physician credentials file review and appointment approval(2) Mental Health• Designated mental health professional to serve on state suicideprevention council or workgroup(3) Women’s Health• Quarterly program updates to VISN leaders• Staff education gap assessments and development of educational material• VISN-level support staff availability

To see our report, click on the link below

In February 2021, the Office of the Chief Information Officer (OCIO) identified funding risks with the development contract under which HUD contracted for Federal Housing Administration (FHA) Catalyst’s development. In response, HUD officials took steps to slow FHA Catalyst spending on the contract while awaiting approval for additional contract funds. Despite efforts to slow project spending, it was not enough to prevent funding shortfalls before the contract’s base year end. Poor contract oversight enabled OCIO to exhaust funds before the end of the base year, which stopped work on FHA Catalyst. Additionally, several issues also hindered FHA Catalyst development activities. As of August 2021, HUD had resumed FHA Catalyst development work at limited capacity. As of October 2021, HUD estimated that it would complete FHA Catalyst development in March 2025.