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 Carl Vinson VA Medical Center and multiple outpatient clinics in Georgia. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.The executive leadership team had worked together for five weeks prior to the OIG’s on-site visit. The leadership team had vacancies in three of the four key positions since the previous healthcare inspection. Survey results revealed opportunities for the executive team to improve employee satisfaction. Patient experience survey results were generally less favorable than Veterans Health Administration national averages. The OIG’s review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Executive leaders were knowledgeable within their scope of responsibilities about selected Strategic Analytics for Improvement and Learning data.The OIG issued 17 recommendations for improvement in seven areas:(1) Quality, Safety, and Value• Committee processes(2) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(3) Medication Management• Quality measure oversight(4) Mental Health• Suicide prevention training(5) Care Coordination• Goals of care conversations(6) Women’s Health• Women’s health primary care providers• Committee membership and attendance(7) High-Risk Processes• Reusable medical equipment inventory file• Standard operating procedures• Annual risk analysis• Eyewash station testing• Quality assurance monitoring• Reprocessing and storage area physical inspections• Competency assessments

What We Looked AtWe contracted with the independent public accounting firm Allmond & Company, LLC, to audit the National Transportation Safety Board’s (NTSB) financial statements as of and for the fiscal years ended September 30, 2020, and September 30, 2019, provide an opinion on those financial statements, and report on internal control over financial reporting, compliance with laws, and other matters. The contract requires the audit to be performed in accordance with U.S. generally accepted Government auditing standards, Office of Management and Budget audit guidance, and the Government Accountability Office’s and Council of the Inspectors General on Integrity and Efficiency’s Financial Audit Manual. We performed a quality control review of Allmond’s report dated November 6, 2020, and related documentation, and inquired of its representatives. What We FoundOur quality control review disclosed no instances in which Allmond did not comply, in all material respects, with U.S. generally accepted Government auditing standards. RecommendationsAllmond made no recommendations.

These challenges illustrate the most significant areas the Office of Inspector General (OIG) believes need improvement for the Peace Corps to effectively manage its resources and minimize the potential for fraud, waste, and abuse occurring in its operations. Addressing the issues related to these challenge areas will enable the agency to increase operational efficiencies and improve mission effectiveness.