Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care coordination for patients of the VA Eastern Kansas Health Care System (system) who received care and were dually prescribed opioids and benzodiazepines from Community Care Network (CCN) providers. The inspection also reviewed compliance with public law and Veterans Health Administration (VHA) policies and guidelines specific to the oversight of CCN provider opioid prescribing practices. The OIG found issues related to incomplete and delayed CCN provider documentation, Opioid Safety Initiative (OSI) prescribing risk mitigation strategies, prescriptions dispensed at VHA pharmacies versus non-VA pharmacies, and lack of medication reconciliation and VHA medication profile updates, which place patients at risk for adverse opioid related events. Additionally, the OIG identified two examples in which patients received multiple controlled substance prescriptions from a combination of system, non-system VHA providers, and CCN providers.The OIG found the Veterans Integrated Service Network (VISN) Director and system staff were not conducting oversight of CCN providers opioid prescribing practices as required under the MISSION Act and as recommended by the OIG in 2019 and were not reporting concerns of unsafe CCN provider practices to the third party administrator.The OIG made seven recommendations to the Under Secretary for Health related to CCN provider documentation, evidence of CCN provider training and use of OSI risk-mitigation strategies, state prescription drug monitoring program queries, and capture of CCN-prescribed medications in electronic health records (EHR). The OIG made two recommendations to the VISN Director related to ensuring the system has processes in place to conduct oversight of CCN providers’ prescribing practices. The OIG made four recommendations to the System Director related to documenting use of OSI risk-mitigation strategies, capturing CCN-prescribed medications in the EHR, filling vacant positions, and educating staff on reporting patient safety concerns involving CCN providers.

Objectives: To (1) determine whether the Social Security Administration had taken corrective action in response to the recommendation in our 2015 review of Self-employment Earnings Removed from the Master Earnings File and (2) review instances where SSA removed self-employment earnings from the Master Earnings File since our 2015 review.

The objective was to determine whether the Social Security Administration’s identity verification controls for the my Social Security portal were compliant with Federal requirements. Our audit report (A-14-18-50486) results contain information that, if not protected, could result in adverse effects to the Agency’s information systems. In accordance with government auditing standards, we have separately transmitted to SSA management our audit’s detailed findings and recommendations and excluded from this summary certain sensitive information because of the potential damage if the information is misused. We determined the omitted information neither distorts the audit results described in this report nor conceals improper or illegal practices.

The attached final report summarizes Ernst & Young LLP’s (Ernst & Young) review of the security of the Social Security Administration’s (SSA) Web Identification, Authentication, and Access Control System. Ernst & Young’s audit results contain information that, if not protected, could result in adverse effects to the Agency’s information systems. In accordance with government auditing standards, we have separately transmitted to SSA management Ernst & Young’s detailed findings and recommendations and excluded from this summary report certain sensitive information because of the potential damage if the information is misused. We have determined the omitted information neither distorts the audit results described in this report nor conceals improper or illegal practices.

Compared to the general population, veterans have a higher risk of opioid overdose due to many contributing factors, along with a higher incidence of medical conditions that increase the risk for opioid use disorder. The MISSION Act of 2018 requires VA to ensure that non VA providers who prescribe opioids to veterans receive and certify the review of VA’s Opioid Safety Initiative (OSI) guidelines. These guidelines require providers to query state prescription drug monitoring programs (PDMPs) to determine whether veterans already have other opioid prescriptions before writing a new opioid prescription. The VA Office of Inspector General (OIG) assessed whether VA ensured non VA providers were provided a copy of the OSI guidelines and certified that they have reviewed them, whether a sample of non VA providers conducted required PDMP queries, and whether sampled veterans’ medical records included opioid prescriptions, as required by the MISSION Act. The Office of Integrated Veteran Care (IVC) did not provide adequate oversight for either the third party administrators or non VA providers to ensure the providers received and certified they reviewed the OSI guidelines. IVC also did not monitor third party administrators to ensure non VA providers are completing PDMP queries as required. The sampled medical records generally contained the non VA provider opioid prescription information as required. However, this information was documented in different sections of the VA medical records, which may make it difficult for providers to access this critical information. The OIG made three recommendations to improve compliance with MISSION Act requirements and OSI guidelines.

This Office of Inspector General Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Corporal Michael J. Crescenz VA Medical Center and associated outpatient clinics in Pennsylvania and New Jersey. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued nine recommendations for improvement in three areas:1. Quality, Safety, and Value• Root cause analysis for patient safety events with a safety assessment code score of 32. Medical Staff Privileging• Ongoing Professional Practice Evaluationso Service-specific criteriao Reprivileging based on datao Results reviewed and documented by Medical Executive Board when making reprivileging recommendations• Focused Professional Practice Evaluation results reported to the Medical Executive Board3. Environment of Care• Inspections at the required frequency• Clean and safe environment• Safe environment in the inpatient mental health unit• Access to medication and supply rooms