An additional quote from the "letter never sent" (except to the OIG)
Please ensure such errors never happen again, whether they were because of a mistaken belief in the veracity of BCAG’s responses, or for whatever reason you ultimately find they were made. Due to the vastness of BCAG in relation to your office’s staffing levels, there is little if any room for such errors. After the investigation of my report and after the corrective actions therefrom restore our Quality System yet again to vitality, finding quickly and extinguishing forever each noncompliance at BCAG to our Quality System will be critical lest small "fires" of such noncompliances at individual BCAG sites then "blow up" yet again BCAG-wide into the vast firestorm of massive noncompliance to our Quality System currently wildly "burning" at BCAG, that only the pulling of our PC will now extinguish.
The Last Inspector