Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Aleda E. Lutz VA Medical Center and multiple outpatient clinics in Michigan. The inspection covers 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; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.The medical center’s executive leadership team appeared stable, although two of the four positions had been filled for less than one year at the time of the OIG’s virtual review. Selected employee satisfaction survey results indicated opportunities for the Associate Director for Patient Care Services to improve workplace perceptions and for the Chief of Staff to support an environment where employees felt less moral distress. Patient experience survey scores reflected lower female satisfaction ratings than VHA averages. The inspection team reviewed accreditation agency findings, sentinel events, and disclosures of adverse patient events but did not find any substantial organizational risk factors. Executive leaders spoke in depth about actions taken during the previous 12 months to maintain or improve employee satisfaction and patient experiences. Leaders were knowledgeable about data used by Strategic Analytics for Improvement and Learning models.The OIG issued nine recommendations in five areas:(1) Quality, Safety, and Value• Improvement action implementation(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit review forms(3) Care Coordination• Goals of care conversations(4) Women’s Health• Women veterans health committee attendance(5) High-Risk Processes• Standard operating procedures• Staff training• Competency assessments

We selected the Olathe East Branch for review based on the number of customer inquiries the unit received. Specifically, there were 1,421 inquiries recorded in the Customer 360 (C360) system from November 2020 through January 2021. Most of the inquiries (1,276, or 89.8 percent) were related to package tracking and delivery. Our objective was to evaluate select mail delivery and customer service operations and determine whether internal controls were effective at the Olathe East Branch.

DOL-OIG Investigations Newsletter Vol. XXXIII for the period of February 1 - March 31, 2021

Our objective was to determine the accuracy of Postal Service Highway Contract Route (HCR) scheduled hours and payments from fiscal years (FYs) 2016 through 2020. We performed a risk assessment of the HCR scheduled trips and determined that of the 82,578 scheduled trips in TCSS from FYs 2016 through 2020, 271 were at high- or medium-risk of their contracted schedules being overstated. We used the average speed of 50 miles per hour from the November 2010 Freight Facts and Figures study issued by the Department of Transportation to calculate trip hours, compared it to the actual trip hours in TCSS, and categorized the differences into high-risk (20 hours or more), medium-risk (five to 20 hours), and low-risk (fewer than five hours). The 271 trips included 130 spotter and shuttle services that we excluded from our review because they do not travel on highways, resulting in 141 at-risk trips for review.

We conducted a review to determine the U.S. Equal Employment Opportunity Commission’s (EEOC) Fiscal Year (FY) 2020 compliance with the Improper Payments Elimination and Recovery Act of 2010 (IPERA) (Public Law 111-204) which amended the Improper Payments Information Act of 2002 (Pub. L. 107-300) (IPIA) and required agencies to identify and review all programs and activities they administer that may be susceptible to significant improper payments based on guidance provided by the Office of Management and Budget (OMB).1 In addition, section 3 of IPERA required Inspectors General to review each agency’s improper payment reporting and issue an annual report.