Federal Reports

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 Hershel “Woody” Williams VA Medical Center and multiple outpatient clinics in Kentucky, Ohio, and West Virginia. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG inspection, all leadership positions were permanently assigned and the executive team had worked together for over one year. The Director and Chief of Staff were assigned in February 2014 and June 2020, respectively. Employee survey data revealed an opportunity for the Director to decrease staff feelings of moral distress at work. Patient experience survey scores generally reflected similar or higher care ratings than the VHA averages, although leaders appeared to have an opportunity to improve female patients’ primary care access. The OIG’s review of the medical center’s accreditation findings did not identify any substantial organizational risk factors. However, the OIG identified concerns with conducting institutional disclosures for sentinel events. Executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue efforts to sustain and improve performance.The OIG issued six recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Institutional disclosures(2) Quality, Safety, and Value• Systems Redesign Coordinator meeting participation• Surgical work group meetings(3) Care Coordination• Inter-facility transfer form completion(4) High-Risk Processes• Disruptive behavior committee meeting attendance

The post office lobby is the principal business office of the U.S. Postal Service. There are over 30,000 leased and owned Postal Service retail facilities nationwide. For most customers, the lobby is their only close-up view of Postal Service operations; therefore, its appearance directly affects the Postal Service’s public image. The Postal Service must maintain a safe environment for both employees and customers, including adherence to federal safety laws enforced by the Occupational Safety and Health Administration (OSHA) and internal policies and procedures regarding the appearance of lobbies and facilities, safety, and security of its facilities.Our objective was to summarize the results of prior property condition reviews of Postal Service retail facilities, identify systemic issues, and assess the effectiveness of management’s corrective actions.

By disclosing nonpublic information, the employees violated regulations that prohibit providing preferential treatment to any private organization.

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 Beckley VA Medical Center and two outpatient clinics in West Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior. At the time of the OIG’s inspection, the medical center’s executive leadership team had worked together for over one year. Employee survey data revealed general satisfaction with leaders. However, opportunities appeared to exist for the Chief of Staff to improve employees’ perceptions toward leaders and the workplace, and for the Chief of Staff, Associate Director/Patient Care Services, and Associate Director to reduce staff feelings of moral distress at work. Patient experience survey scores implied satisfaction with the care provided, but highlighted opportunities for leaders to improve female patients’ experiences with specialty care providers. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning model measures and should continue to take actions to sustain and improve performance. The OIG issued four recommendations for improvement in four areas: (1) Quality, Safety, and Value • Surgical workgroup meetings (2) Mental Health • Suicide safety plan training (3) Care Coordination • Medication list transmission (4) High-Risk Processes • Prevention and management of disruptive behavior training

The VA Office of Inspector General (OIG) conducted this inspection to determine whether the Tucson Consolidated Mail Outpatient Pharmacy (CMOP) was meeting federal security guidance. The inspection team selected the Tucson CMOP because it is home to the CMOP Local Area Network, which establishes an interface for electronically transferring information between all Veterans Health Administration medical centers and the CMOP host systems located at each of the seven CMOPs, which form an integrated and highly automated outpatient prescription dispensing system.The OIG team found deficiencies in configuration management, contingency planning, and access controls. Specifically, the Tucson CMOP had inaccurate component inventories, ineffective vulnerability management, and inadequate flaw remediation and had not implemented the configuration management plan; lacked a disaster recovery plan; and had not changed the default username and password for the security camera system and did not consistently generate or forward audit records to the Cybersecurity Operations Center. Without these controls, VA may be placing critical systems at unnecessary risk of unauthorized access, alteration, or destruction. The OIG made six recommendations to the Tucson CMOP director: implement effective inventory management tools, an effective vulnerability and flaw remediation program, and a disaster recovery plan; ensure CMOP staff understand their assigned roles and responsibilities; task the facility manager to change the default username and password for the security camera system; and request the Office of Information and Technology to configure audit logging on the misconfigured devices in accordance with established baselines, policy, and procedures.