Federal Reports

The VA OIG conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the James J. Peters VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; and High-Risk Processes: Moderate Sedation. OIG also provided crime awareness briefings to 162 employees. The facility had generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. OIG noted findings in the 5 areas of clinical operations reviewed and issued 15 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Frequency of Quality Executive Board meetings• Review of credentialing and privileging data• Utilization management reviews and documentation(2) Medication Management: Anticoagulation Therapy• Use of quality assurance data (3) Coordination of Care: Inter-Facility Transfers• Transfer data reporting and analysis• Documentation for acute patient transfers to other facilities(4) Environment of Care• Environment of Care rounds attendance• Panic alarm and security surveillance television system testing• Interdisciplinary Safety Inspection Team training(5) High-Risk Processes: Moderate Sedation• Monitoring of moderate sedation outcome data• Performance of history and physical examinations and pre-sedation assessments• Clinical staff training

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Providers incorrectly billed diagnosis code 260 for Kwashiorkor for inpatients who did not have the disease. We reviewed the medical records for 2,145 inpatient claims at 25 providers and found that all but 1 claim incorrectly included the diagnosis code for Kwashiorkor, resulting in overpayments in excess of $6 million.

We conducted this review to assess the Indian Health Service's (IHS) physical and information technology controls over prescription drugs such as opioids and to identify measures that could prevent drug diversions.