Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations of inadequate preoperative evaluations and the management of postoperative care for a patient approved for bariatric surgery at the VA Pittsburgh Healthcare System. The patient did not receive three required laboratory tests prior to bariatric surgery; however, the OIG did not substantiate that the patient was inappropriately approved for surgery. These omissions did not affect the clinical indication for surgery or the outcome. The OIG did not substantiate that the patient was inadequately evaluated by mental health providers prior to surgery. The Bariatric Surgery Program team considered the patient’s complex mental health history prior to approving the patient for surgery. The OIG substantiated that the Managing Overweight and/or Obesity for Veterans Everywhere coordinator overstated the patient’s mental health treatment and did not correct the documentation error after discovering it. Concerns were noted regarding the lack of a checklist and the use of informal communication instead of documenting interdisciplinary team discussions. The OIG concluded that an improved process could diminish the risk of an incomplete preoperative evaluation for future patients. The patient successfully underwent bariatric surgery in 2019. The OIG did not substantiate that the patient was insufficiently monitored following surgery. The patient received monitoring for medication, weight loss, and mental health symptoms. Approximately three months after surgery, the patient was seen in the Emergency Department and denied thoughts of self-harm in the previous two weeks. The patient completed suicide five days after the Emergency Department visit. The OIG made six recommendations to the Facility Director related to developing a facility policy for bariatric surgery; ensuring bariatric patients receive all preoperative medical and mental health evaluations; reviewing, correcting, and educating staff on documentation errors; documenting preoperative bariatric interdisciplinary team discussions; and reviewing the Bariatric Surgery Program.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Oscar G. Johnson VA medical center and multiple outpatient clinics in Michigan and Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The medical center’s executive leadership team included four positions, one was permanently filled less than four months and one (chief of staff) had been vacant for three months prior to the OIG visit. Employee satisfaction survey results for the Director and the ADPCS were markedly higher than VHA averages. Leaders supported efforts to improve and maintain patient safety, quality care, and other positive outcomes. The leadership team was extremely knowledgeable within their scope of responsibility about Strategic Analytics for Improvement and Learning data and should continue to act to sustain and improve performance. No substantial organizational risk factors were identified. The OIG issued 11 recommendations for improvement: (1) Medical Staff Privileging • Professional practice evaluation processes (2) Medication Management • Aberrant behavior risk assessment • Urine drug testing • Informed consent • Follow up after therapy initiation • Pain Committee activities (3) Women’s Health • Women Veterans Program Manager collateral duties (4) High-Risk Processes • Sterile Processing Services annual risk analysis • Staff training

The objective for this report was to evaluate the extent to which the company employs key practices to ensure the efficiency and effectiveness of its police force. We found that, over the past two years, the company has significantly improved its oversight and management of its police department but has not reached a consensus on the full scope of Amtrak Police Department’s (APD) role and priorities—a foundational decision from which all other policing decisions flow. Further, the company has not developed systematic processes to determine APD’s optimum size or composition. As a result, the company does not have reasonable assurance that it is using its police department efficiently and effectively and could be exposed to unforeseen risks to its security, operations, finances, and brand.To better ensure that APD is effectively and efficiently meeting the company’s needs and addressing its risks, we recommended that the company and police department reach a consensus on the full scope of APD’s role and priorities. Once it has done so, we recommended that the company develop data‐driven, risk‐based processes to determine the department’s optimal size and staffing composition and ensure that those decisions—as well as decisions about allocation, goals, and metrics—align with APD’s role and priorities.

OIG evaluated FSIS’ controls to ensure the safety of imported meat and poultry.

We found violations of U.S. Immigration and Customs Enforcement (ICE) detention standards undermining the protection of detainees’ rights and the provision of a safe and healthy environment. Although the conditions varied among the facilities and not every problem was present at each, our observations, interviews with detainees and staff, and review of documents revealed several common issues. At three facilities, we found segregation practices infringing on detainee rights. Detainees at all four facilities had difficulties resolving issues through the grievance and communication systems, including allegations of verbal abuse by staff. Two facilities had issues with classifying detainees according to their risk levels, which could affect safety. Lastly, we identified living conditions at three facilities that violate ICE standards. We recommended the Acting Director of ICE ensure the Enforcement and Removal Operations field offices overseeing the detention facilities covered in the report address identified issues and ensure facility compliance with relevant detention standards. We made one recommendation that will help ICE ensure compliance with detention standards. ICE concurred with the recommendation.