Federal Reports

Management Challenges – Fiscal Year 2019

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Canandaigua VA Medical Center, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. The areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leaders were all permanently assigned for seven months prior to the OIG’s inspection and seemed actively engaged with employees and patients. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The OIG noted continuing challenges regarding the facility’s integration with the Bath VA Medical Center to form the VA Finger Lakes Healthcare System. The leadership team were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics, but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “5-star” quality ratings. The OIG issued 14 recommendations for improvement: (1) Environment of Care • Medical equipment storage • Panic alarm testing • Environmental safety and repair • Patient information protection (2) Controlled Substances Inspections • Reconciliation of one-day’s dispensing and order verification • Controlled substances coordinator maintaining oversight (and refrain from conducting routine inspections) • Verification of hard copy prescriptions (3) Military Sexual Trauma (MST) Follow-up and Staff Training • MST coordinator responsibilities • MST mandatory training (4) Antidepressant Use among the Elderly • Education and evaluation of the education provided • Medication reconciliation (5) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Maryland Health Care System, Baltimore, Maryland, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. Executive leadership appeared relatively stable. Employee satisfaction scores were generally better than VHA averages; however, patient experience results identified improvement opportunities. Leaders appeared to support efforts to improve and maintain patient safety, quality care, and positive outcomes. Review of accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. Leaders were knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance measures contributing to the current SAIL ratings. The OIG issued 23 commendations for improvement: (1) Quality, Safety, and Value • Peer review processes • Interdisciplinary review of utilization management data • Root cause analysis processes • Compliance with life-sustaining treatment orders • Review of resuscitative episodes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Reprivileging processes (3) Environment of Care • Environmental cleanliness • Furniture and equipment condition • Infection prevention and control • Panic alarm installation and testing (4) Medication Management: Controlled Substances Inspections • Monthly controlled substances inspections • Emergency drug cache inspections (5) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • Military sexual trauma training (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Tracking and monitoring cervical cancer data

The Office of the Inspector General conducted a review of the Hydro Dispatch Control Center (HDCC) to identify operational and cultural strengths and risks that could impact HDCC’s organizational effectiveness. Our report identified strengths within HDCC related to (1) organizational alignment, (2) positive interactions within and outside of HDCC, (3) effective leadership, and (4) positive ethical culture. However, we also identified risks that could impact HDCC’s ability to meet its responsibilities in support of Power Operations’ mission. These were comprised of risks including (1) perceptions of lack of effective accountability and (2) execution-related concerns related to inadequate night shift staffing and workspace issues in the System Operations Center.

We contracted with CliftonLarsonAllen LLP (CLA), an independent certified public accounting firm, to perform the audit. This management letter summarizes CLA’s findings and recommendations related to internal control deficiencies and other matters. The issues noted in this report are not significant; therefore, the deficiencies were not required to be reported in the Independent Auditor’s Report Statements (AUD-2020-2/FA-19-137-1). During the FY 2019 audit, CLA did not identified any new internal control deficiencies of less significant matters to be included in this report. CLA, as part of their work, followed up on open recommendations included in the previous years' management letter and closed one recommendation.