Federal Reports

The Philadelphia P&DC is in the Philadelphia District within the Eastern Area. The P&DC processes letters, flats, and parcels. From July 1 to December 31, 2019, it reported 13,206 late trips (third highest among P&DCs) and 1,297 extra trips (40th highest among P&DCs) from the plant to delivery units. Our objective was to assess the causes of late and extra trips at the Philadelphia P&DC.

OIG reviewed USDA’s compliance with improper payment requirements and the Department’s high-dollar overpayments reports for fiscal year 2019.

The VA Office of Inspector General (OIG) conducted this healthcare inspection to respond to allegations related to inadequate nurse staffing and nurse-to-patient ratios in the Critical Care Unit (CCU) purportedly resulting in poor quality of care, which included the development of pressure ulcers, inadequate cardiac and respiratory care, and intravenous medication management failures. Lack of consistent documentation prevented the OIG from determining whether nurse staffing contributed to many of the conditions outlined in the allegations. The CCU daily nurse assignment sheets did not consistently document which bed a patient occupied or the nurse-to-patient assignment. The OIG identified noncompliant facility practices and other deficits that contributed to care management challenges and increased risk for poor clinical outcomes. The facility failed to designate a committee, required by Veterans Health Administration (VHA) and its own policies, to develop, implement, monitor, and evaluate the Pressure Ulcer Prevention Program. Facility staff with relevant wound care knowledge met periodically as the Skin and Wound Care Committee and provided pressure injury data to other committees, but there was limited evidence of analysis, action, or follow-up. Additionally, some CCU nurses did not know about the facility policy requirement to initiate wound care consults for patients at high risk for pressure injuries. Facility and tele-intensive care unit (ICU) staff also did not immediately recognize and respond to a life-threatening arrhythmia, which may have contributed to a patient’s death. Other OIG-identified deficits related to respiratory care, sitter availability, and medication management. The OIG made recommendations to the Facility Director regarding compliance with VHA and local requirements for pressure injury prevention and management including nursing documentation. Other recommendations focused on tele-ICU and cardiac monitoring, the respiratory care for a specific patient, processes for securing sitters when ordered, and CCU nursing staff assignment practices.