Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of allegations related to the management of staff exposure to a patient diagnosed with COVID-19 at the VA Portland Medical Center (facility) in Oregon. The events under review involved the facility’s first patient diagnosed with COVID-19. The OIG did not substantiate that emergency department staff failed to notify imaging department staff that a patient was suspected to have COVID-19 before sending the patient to the imaging department. At the time of the patient’s transport to the imaging department, emergency department staff had not identified suspicion of COVID-19. However, emergency department staff failed to alert imaging department staff of the patient’s potential influenza. The OIG did not substantiate that imaging department supervisors failed to properly and promptly notify imaging department staff who had contact with a patient who was diagnosed with COVID-19 after admission to the facility, or that leaders failed to take appropriate action following staff exposure to a patient with COVID-19. The OIG identified some missteps in the facility’s processes when responding to staff exposure, which affected the accuracy of exposure risk assessments and monitoring for some exposed staff. While missteps were noted, the facility made a significant and timely effort to identify staff with potential exposure and respond in accordance with the most current guidance from the Centers for Disease Control and Prevention and Oregon Health Authority. Facility leaders and infection prevention and control staff developed and revised COVID-19-related policies as new guidance became available. The OIG made five recommendations to the facility director related to communicating infection control precautions prior to transfer, management of staff with exposure to high-consequence infections, and inclusion of a detailed staff exposure management process in relevant facility policies.

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 Captain James A. Lovell Federal Health Care Center and outpatient clinics in Illinois and Wisconsin. The inspection covers key clinical and administrative processes 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. At the time of this inspection, the healthcare center’s leaders had been working together for four months. Employee satisfaction survey results revealed opportunities for the Chief Medical Executive and VA Chief Nurse Executive to improve employees’ feelings of “moral distress” at work. Patient experience surveys indicated general satisfaction; however, female veteran scores were less favorable. The leaders were knowledgeable within their scopes of responsibility about Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance. The OIG issued 27 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Committee processes • Utilization Management processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluations • Provider exit reviews (3) Environment of Care • Environmental cleanliness • Privacy and security (4) Medication Management • Quality measure oversight (5) Mental Health • Suicide prevention training (6) Women’s Health • Primary Care Mental Health Integration services • Community-based outpatient clinic women’s health primary care providers • Women Veterans Health Committee membership • Quality data monitoring (7) High-Risk Processes • Standard operating procedures • Annual risk analysis • Airflow testing • Eyewash station testing • Environmental cleanliness • Equipment storage and tracking • Staff training

Delivery System Reform Incentive Payment (DSRIP) Program payments are incentive payments made to hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality and cost-effectiveness of care, and increase the health of patients and families served. These incentive payments have significantly increased funding to providers for their efforts related to the quality of services. Texas made DSRIP Program payments totaling almost $10 billion for 5 years.Our objective was to determine whether Texas used permissible funds as the State share of DSRIP Program payments.

DHS components used inconsistent processes for administrative forfeitures under the Civil Asset Forfeiture Reform Act of 2000 (CAFRA). Specifically, we found inconsistencies among DHS components regarding the forms used to notify property owners and the process for responding to claims. Further, CBP inappropriately used waivers to extend deadlines for responding to claims. We recommended DHS implement a department-wide structure to oversee component forfeiture activities across DHS by designating an office at headquarters for this role. Additionally, DHS should develop Department-wide policies and procedures, as well as review component policies, to ensure forfeiture processes and practices are consistent. We made two recommendations to improve oversight across DHS and provide consistent processes for handling administrative forfeitures. DHS concurred with recommendation two, which we consider resolved and open, but did not concur with recommendation one, which is unresolved and open.

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 Clement J. Zablocki VA Medical Center and multiple outpatient clinics in Wisconsin. 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 medical center’s executive leadership team had been working together for over two years. Employee satisfaction survey results revealed opportunities for the Deputy Director and Assistant Director to decrease employee feelings of moral distress at work. Patient experience survey data noted satisfaction with care. Survey results for males and females were generally more favorable than VHA results nationally. The review of accreditation findings did not identify any substantial organizational risk factors. The OIG identified significant concerns with sentinel events identification. Executive leaders were generally able to speak knowledgeably about actions taken during the previous 12 months to maintain or improve performance, and were knowledgeable within their scopes of responsibilities about Strategic Analytics for Improvement and Learning data. The OIG issued 28 recommendations for improvement in seven areas:(1) Quality, Safety, and Value • Committee processes • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Safety and cleanliness • Information security (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up (6) Women’s Health • Gynecologic care coverage • Committee membership • Quality data • Women veteran program manager position (7) High-Risk Processes • Annual risk analysis • Environmental cleanliness • Equipment storage