Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate a primary care provider’s completion of electronic health record (EHR) documentation within the facility’s required time frame and accumulation of over 4,000 view alerts (EHR notifications) that may have resulted in patients’ adverse clinical outcomes. Also reviewed were actions taken by facility leaders to address the provider’s EHR documentation deficiencies.The OIG’s review of 220 identified patients’ care did not find adverse clinical outcomes related to the provider’s delinquent documentation. The OIG was unable to determine if patients experienced adverse clinical outcomes from the provider accumulating 4,000 view alerts, because the view alerts were addressed prior to the OIG inspection. Once addressed, view alerts are no longer active or viewable. Facility leaders reported finding no adverse clinical outcomes resulting from these view alerts.Facility leaders implemented actions to address the provider’s documentation deficiencies and monitored the provider for sustainable compliance with documentation requirements. The provider no longer treats patients at the facility.High numbers of accumulated view alerts were not isolated to the provider. However, facility leaders implemented strategies to reduce the number, and facility data showed a reduction of accumulated view alerts. Facility leaders need to continue to develop and implement strategies to manage and evaluate the effectiveness of view alerts and assess the need for retrospective reviews of patient care related to accumulated view alerts.During the inspection, the OIG also found that Health Information Management staff were not monitoring EHRs for patient care episodes without associated progress notes and facility policy did not define the time frame for providers to respond to view alerts as required by the Veterans Health Administration.The OIG made three recommendations related to providers’ view alert time frames and monitoring EHRs and view alerts.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 10: VA Healthcare System Serving Ohio, Indiana and Michigan in Cincinnati, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this virtual site visit during concurrent reviews of VISN 10 facilities.Executive leaders had worked as a team for three months at the time of the OIG’s virtual site visit. Employee satisfaction survey score were higher than Veterans Health Administration (VHA) averages. Patient experience survey scores were similar to or higher than VHA averages. VISN leaders had an opportunity to reduce wait times and clinical vacancies.Leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. They were also knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning metrics and should continue to take actions to sustain and improve performance.The OIG issued seven recommendations for improvement in three areas:(1) Medical Staff Credentialing• Documented review of physician credentialing files prior to VA appointment(2) Women’s Health• Appointment of a VISN lead women veterans program manager• Quarterly program updates to executive leaders• Annual site visits at each facility(3) High-Risk Processes• VISN-led facility reusable medical equipment inspection results• Electronic posting of inspection results• VISN oversight of facility corrective action plan development and action item tracking

We did not substantiate allegations that the National Park Service improperly hired a senior political employee.

During research we found the 1915(c) Community Integration and Habilitation Waiver (CIH Waiver) services that Indiana reported on the Form CMS-64 accounted for just over $1.1 billion in Medicaid expenditures during Federal fiscal years (FFYs) 2015 and 2016. These expenditures represented approximately 5.9 percent of the total Medicaid expenditures reported on the Form CMS-64 during this period. We decided to perform this audit of the CIH Waiver services because of the significant dollar expenditures. Our objective was to determine whether Indiana ensured that CIH Waiver services at 12 selected providers were provided in accordance with Federal, State, and waiver requirements.