Federal Reports

The VA Office of Inspector General (OIG) reviewed a former VA surgeon’s eligibility to provide health care as a participant in VA’s Community Care Network (CCN) and the Marion VA Health Care System’s (facility) management of community care patient safety events.The OIG identified multiple failures by third-party administrator (TPA), Optum, and VA Office of Integrated Veteran Care (IVC) that undermined credentialing and oversight processes, and ultimately allowed the subject surgeon to practice in the VA community care program. First, Optum failed to address concerns identified by a third-party certified verification organization in the surgeon’s 2018 credentialing file. Second, imprecise language in the VA’s contract with the TPA did not provide adequate guidance for Optum in determining whether to exclude the surgeon from the CCN. Additionally, IVC failed to identify inconsistencies in the surgeon’s credentialing file that should have impacted credentialing decisions. Finally, misapplication of privacy rules prevented Optum’s leaders from releasing important information to IVC relevant to the surgeon’s voluntary relinquishment of the Florida medical license. The OIG concluded that the facility’s patient safety training did not include completing patient safety event reports for events in the community and the patient safety manager was unaware of the ability to contact the TPA for updates on the status of patient safety concerns reported to the TPA.The OIG made two recommendations to the Under Secretary for Health related to review of the surgeon’s eligibility to participate in the CCN and CCN contract; four recommendations to the IVC Executive Director related to ensuring Optum’s sufficient review, documentation, and compliance of CCN providers; one recommendation to the VISN Director to review all community care provided by the surgeon; and one recommendation to the Facility Director related to patient safety event report education and follow-up.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued four recommendations for improvement in three areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations o Equivalent specialized training and similar privileges o Service-specific criteria2. Environment of care• Safe and clean environment3. Mental health• Comprehensive Suicide Risk Evaluation completion

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Miami VA Healthcare System, which includes the Bruce W. Carter VA Medical Center and multiple outpatient clinics in Florida.This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued two recommendations for improvement in two areas:1. Quality, safety, and value• Peer reviews for unanticipated deaths within 24 hours of admission2. Medical staff privileging• Completion of Ongoing Professional Practice Evaluations for licensed independent practitioners

An Amtrak Train Attendant based in Miami, Florida, was terminated from employment on January 2, 2024, following our investigation. Our investigation found that the employee violated company policies by engaging in outside employment at several companies while on a medical leave of absence. During her interview, the employee admitted that she was employed full-time with various employers from 2019 through 2023.

Our objective was to determine whether the Postal Service was effectively testing and monitoring the performance of, providing effective oversight over the contract for, and storage of, charging stations. We observed testing at Vienna, Virginia; conducted site observations and interviews at the MDC; and reviewed related policies and procedures.

We performed a self-initiated audit at the Chicago Processing and Distribution Center and four delivery units serviced by the P&DC during the week of July 24, 2023. The delivery units included the Cragin, Daniel J. Doffyn, Northtown, and Roger P. McAuliffe StationsWe issued individual reports for the four delivery units and the P&DC we visited.We issued a report summarizing the results of our audits at all four delivery units with specific recommendations for management to address.