Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that staff at the facility denied a patient’s discharge requests and did not ensure the patient’s access to a patient advocate. The inspection also evaluated OIG-identified concerns related to Inpatient Mental Health Unit and Community Living Center (CLC) staff’s administrative actions during the patient’s admissions.The OIG substantiated that staff denied the patient’s discharge requests. The OIG found that staff failed to follow informed consent procedures. The OIG also found that staff did not conduct a sufficient or timely decision-making capacity evaluation and documented unsupported, conflicting decision-making capacity information in the patient’s electronic health record.The patient remained on voluntary status during Inpatient Mental Health Unit and CLC admissions for nearly 2 years and 11 months. Staff did not adequately assess the patient’s admission status as voluntary or involuntary and did not follow commitment requirements during the first two of the patient’s three Inpatient Mental Health Unit admissions.The OIG found that staff did not comply with requirements when the patient requested an against medical advice discharge. The OIG also determined that staff did not properly identify a surrogate decision-maker and did not address ethical concerns regarding the appropriateness of the patient’s surrogate decision-maker.The OIG substantiated that staff failed to ensure the patient’s access to the patient advocate. Staff did not properly manage a letter from the patient that was intended for a public official.The OIG made seven recommendations to the Facility Director related to informed treatment consent processes, decision-making capacity evaluation completion and documentation, commitment requirements, against medical advice discharge procedures, surrogate decision-maker assignment, patient advocate reporting and tracking processes, and management of the patient’s correspondence request.

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 White River Junction VA Medical Center, which includes outpatient clinics in New Hampshire and Vermont. 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; 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.When the OIG conducted the virtual review, the executive leadership team had worked together for over one year. Employee satisfaction survey results demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected. However, responses also pointed to opportunities for the Director and Chief of Staff to improve employee feelings of moral distress at work. Patient experience survey results indicated satisfaction with the care provided. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue efforts to sustain and further improve medical center performance.The OIG issued two recommendations for improvement in two areas:(1) Quality, Safety, and Value• Surgical work group meetings(2) High-Risk Processes• Disruptive behavior training

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the outpatient settings of the Manchester VA Medical Center. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; 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.The leadership team appeared stable, with a vacancy in only one of four key positions. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. However, the OIG noted opportunities to improve servant leadership behaviors and reduce staff feelings of moral distress at work. Patient experience survey results indicated opportunities to improve female veterans’ satisfaction in the outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued seven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Surgical work group attendance(2) Care Coordination• Monitoring and evaluation of patient transfers• Transfer form completion• Medication list transmission• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Staff training

The Menlo Park (owned), Excelsior (leased), and Sutter Street (leased) post offices are in the California 1 District. The Postal Service is required to maintain a safe and healthy environment for both employees and customers in accordance with its internal policies and procedures and Occupational Safety and Health Administration (OSHA) safety laws. Our objective was to determine if Postal Service management is adhering to building maintenance, safety and security standards, and employee working condition requirements at post offices.We found that building maintenance, safety, and security at the Menlo Park, Excelsior, and Sutter Street post offices did not meet prescribed standards. We identified 50 deficiencies at the three facilities that ranged from minor to more serious violations.

We performed procedures agreed upon by the U.S. Office of Personnel Management’s (OPM) Office of the Chief Financial Officer. This attestation engagement is an annual requirement of the U.S. Office of Management and Budget.Our objective was to assist the OPM in assessing the reasonableness of Postal Service employee health benefits, life insurance, and retirement withholdings; Postal Service benefit contributions; and enrollment information submitted via the headcount report.