Federal Reports

This audit examined the Agency’s processes for estimating, tracking, and reporting life-cycle costs and questioned whether current practices support transparency and accountability.

In June 2021, a complainant alleged that the then acting principal deputy under secretary for health had been informed in the fall of 2019 that VHA’s patient wait times reporting may be misleading but that no action was taken in response. After an initial examination, the OIG determined that there was no basis to proceed with a misconduct investigation of the then acting principal deputy under secretary for health, as the OIG found no evidence of intent or efforts to mislead. This management advisory memo, however, details how VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations. Since 2014, VHA has employed several different methodologies (particularly using different start dates) for calculating wait times reported online, as well as for determining whether wait time criteria are met for community care program eligibility. The methodologies deviated in some instances from VHA’s scheduling directive and its stated wait time measures announced in the Federal Register in 2014. As a result, VHA has presented wait times with different methodologies, using inconsistent start dates that affect the overall calculations without clearly and accurately presenting that information to the public. The OIG found that efforts to improve wait time disclosures had been under consideration but had been deferred by urgent priorities, including the COVID-19 pandemic. VHA’s efforts to improve the accuracy in its reporting of the timeliness of veterans’ access to care are dependent on the consistency of its calculations of wait times and its transparency regarding which methodologies and data sources have been used, together with any limitations. This memo serves to alert VA of the problems identified regarding wait time calculations and reporting, and requests that VA inform the OIG what action is taken to address the identified issues.

The VA Office of Inspector General (OIG) conducted an inspection to assess VA medical facilities’ compliance and processes regarding Veterans Health Administration (VHA) policies for reporting healthcare professionals to state licensing boards (SLBs) and the National Practitioner Data Bank (NPDB).The OIG found widespread noncompliance with SLB and NPDB reporting processes applied by facilities to healthcare professionals whose conduct or competence led to separation from employment. Failure to comply with reporting policies leaves SLBs and recipients of NPDB information unaware of a healthcare professional’s practice deficiencies and ultimately violates an important VA commitment to protect the health of veterans and the public. Moreover, the OIG found a lack of programmatic oversight of compliance with SLB and NPDB reporting processes.For a majority of cases involving separated healthcare professionals, facility directors failed to follow mandatory processes for reporting healthcare professionals to SLBs. The OIG identified SLB reporting noncompliance was related to staff misunderstanding policy and poor facility processes.In 15 of 35 physician or dentist cases appealing a separation from employment, facility directors failed to submit NPDB reports as required by federal regulation and VHA policy. Conflicting language in VHA policies, misunderstanding of policies, and poor facility processes contributed to the failures.VHA SLB and NPDB reporting policies did not assign programmatic oversight to ensure facility leaders’ compliance with SLB and NPDB reporting processes. The lack of programmatic oversight contributed to the failure of VHA leaders to detect and intervene upon facility noncompliance.The OIG made four recommendations to the Under Secretary for Health regarding ensuring SLB and NPDB reporting compliance and programmatic oversight as well as aligning NPDB policy with federal regulation.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Networks (VISNs) 2, 5, and 6 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISNs 2, 5, and 6 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure information is provided in a comprehensive manner, given the changing landscape as infection rates and demands on facilities continue to shift. Findings of inspected medical facilities are grouped by VISN, which are regional systems that provide oversight of medical centers in their area.This report, the fourth in a series, describes findings on COVID-19 practices from healthcare inspections performed within VISNs 2, 5, and 6 during the third and fourth quarters of fiscal year 2021 (April 1 through September 30, 2021). It provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of September 2021. Additionally, it includes information on COVID-19 vaccination efforts, based on a review of VA’s vaccination statistics as of September 29, 2021. Interviews and survey results provide additional context on lessons learned and perceptions of readiness and response.This report aims to provide the nation’s largest integrated healthcare system with relevant information to use in its efforts toward innovation and transformation to meet the healthcare needs of our nation’s veterans.

Prior to landing humans on the Moon as part of the Artemis program, NASA is developing new science instruments to explore the lunar surface including VIPER, a rover that will survey the Moon’s water ice to see if people can “live off the land.” In this report, we assessed NASA’s management of the VIPER project.

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 VA Western New York Healthcare System. 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; 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.The healthcare system’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together for about five months, although some had served in their positions for multiple years. Employee survey data revealed opportunities for leaders to improve workplace satisfaction and reduce feelings of moral distress. Patients generally appeared satisfied with their care. The inspection team reviewed accreditation agency findings and disclosures of adverse patient events and did not identify substantial organizational risk factors. However, the OIG identified concerns related to sentinel event identification and reporting. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued seven recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Identification and reporting of sentinel events(2) Quality, Safety, and Value• Peer review committee recommendation of improvement actions• Surgical work group attendance(3) Care Coordination• Monitoring and evaluation of inter-facility transfers(4) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training