Federal Reports

The VA Office of Inspector General (OIG) received allegations of inadequate orientation and training of pharmacy staff, a lack of pharmacist oversight of intravenous (IV) admixtures, and noncompliance with controlled substance policies. The Veterans Integrated Service Network Director initially reviewed the matter and did not substantiate the allegations but noted that some pharmacy staff’s annual IV compounding competencies had lapsed. The OIG received a second allegation that pharmacy management was noncompliant with Veterans Health Administration (VHA) controlled substance policies and initiated a healthcare inspection to evaluate the allegations and review the annual IV compounding competencies. The OIG did not substantiate inadequate pharmacist orientation and training for inpatient pharmacy, IV admixture, and the cache, and did not substantiate a lack of pharmacist oversight in technician-prepared IV admixtures. The annual required staff competencies were current. However, the OIG team noted the orientation checklists and annual competencies lacked a tracking mechanism. Pharmacy managers complied with the VHA controlled substance directive. The OIG team learned of a suspected controlled substance diversion incident that facility leaders reported to the VA police and the OIG Office of Investigations but did not report to the email group required by the VHA directive at the time. The OIG team learned of an instance where testosterone was not added to inventory records or secured in the vault. The OIG made three recommendations to the Facility Director related to developing a tracking process for orientation and annual competencies of pharmacy staff, ensuring facility leaders are trained on current VHA drug diversion reporting requirements, and conducting a review of the testosterone misplacement. Note: This matter is not related to the recent criminal case involving a former nursing assistant at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

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 William S. Middleton Memorial Veterans Hospital and multiple outpatient clinics in Illinois and Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 executive leadership team appeared stable, with all positions assigned. Survey results indicated that employees were generally satisfied and seemed consistent with the medical center’s high-performing Best Place to Work performance measure. Patient survey results were notably higher than corresponding VHA averages; however, female patients were generally less satisfied. The OIG identified concerns with poor communication among program leaders as a vulnerable area for the medical center. Executive leaders were generally knowledgeable about Strategic Analytics for Improvement and Learning measures and should continue to take actions to improve and sustain performance. The OIG issued 16 recommendations for improvement in six areas: (1) Quality, Safety, and Value • Improvement action implementation • Utilization management data review (2) Medical Staff Privileging • Professional practice evaluation processes • Provider exit review forms (3) Environment of Care • Medical equipment inspections • Medication storage (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up after therapy initiation (5) Mental Health • Staff training (6) High-Risk Processes • Annual risk analysis • Traffic flow restriction • Temperature and humidity monitoring • Staff competency and continuing education

The Social Security Act requires that each Medicare administrative contractor (MAC) have its information security program evaluated annually by an independent entity. The Centers for Medicare & Medicaid Services (CMS) contracted with Guidehouse, LLP (Guidehouse), to evaluate information security programs at the MACs, using a set of agreed-upon procedures (AUPs). HHS OIG must submit to Congress annual reports on the results of these evaluations, to include assessments of their scope and sufficiency. This report fulfills that responsibility for fiscal year 2019.

The OIG investigated allegations that Bureau of Indian Education (BIE) Facilities employees Simon Nunez, David Parrish, and Leland Martinez and San Felipe School employees Ruby Montoya and Nancy Nunez made personal purchases on their assigned Government charge cards.Parrish and Martinez admitted to purchasing personal items, including sheds, tankless water heaters, computers, and tools, with their Government purchase charge cards between August 2013 and December 2016. Simon Nunez, a BIE Facilities Manager, directed the purchases and kept some of the stolen property. Nunez purchased three computers, two of which she converted for personal use and one of which she gave to Montoya to be converted to personal use. Montoya authorized Nunez to purchase one computer, which Montoya converted to personal use.Simon Nunez pleaded guilty in U.S. District Court for the District of New Mexico to nine counts of theft, conspiracy, and false statements. He was sentenced to 6 months in prison followed by 24 months of supervised release and was ordered to pay $6,664.52 in restitution, a $900 special assessment, and a $5,000 fine. Simon Nunez left Federal service on December 23, 2016.Parrish pleaded guilty in U.S. District Court for the District of New Mexico to four counts of conspiracy and theft. He was sentenced to 18 months of probation and was ordered to pay $2,035.51 in restitution, a $400 special assessment, and a $2,500 fine. Parrish left Federal service on December 23, 2016.Martinez pleaded guilty in U.S. District Court for the District of New Mexico to five counts of conspiracy and theft. He was sentenced to 24 months of probation and was ordered to pay $2,895 in restitution, a $500 special assessment, and a $500 fine. Martinez left Federal service on November 6, 2019.Montoya pleaded guilty in U.S. District Court for the District of New Mexico to unlawful conversion of government property and was sentenced to 12 months of probation and was ordered to pay a $2,000 fine. Montoya left Federal service on February 10, 2017.Nancy Nunez pleaded guilty in U.S. District Court for the District of New Mexico to three counts of unlawful conversion of government property and was sentenced to 24 months of probation and was ordered to pay a fine of $8,879 and a special assessment of $300. Nancy Nunez left Federal service on April 14, 2017.

We investigated allegations that Lawrence Killsback, while serving as President of the Northern Cheyenne Tribe (NCT), submitted fraudulent travel claims. The funds used to pay the fraudulent claims came from federally funded NCT programs. Our investigation focused on Killsback’s regional travel in Montana, Wyoming, and South Dakota. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) conducted a parallel investigation that focused on Killsback’s remaining domestic trips.Together, the parallel investigations found that Killsback stole over $20,000 from NCT programs by submitting multiple fraudulent travel vouchers between August 18, 2014, and August 25, 2017.This investigation was prosecuted jointly with the HHS OIG investigation. Killsback pleaded guilty in U.S. District Court for the District of Montana to one count of wire fraud in violation of 18 U.S.C. § 1343 and one count of false claims conspiracy in violation of 18 U.S.C. § 286. On December 12, 2019, Killsback was sentenced to 6 months in prison and 3 years of supervised release. Killsback was also ordered to pay a $200 special assessment and $25,092 in restitution.

The Postal Accountability and Enhancement Act of 2006 requires that each class of mail or type of mail service covers their direct and indirect costs. Over the past 10 years, several U.S. Postal Service market dominant products continuously failed to cover their attributable costs. Currently there are six market dominant products that are not covering their direct and indirect costs (underwater products). In fiscal year (FY) 2019, total loss from these underwater products was about $1.6 billion. Further, some market dominant mail products have had notable declines in cost coverage over the last 10 years. Unlike competitive products, market dominant product price increases are restricted to the Consumer Price Index, with a price cap applied to each mail class. Our objective was to evaluate opportunities to reduce mail product costs. This audit was initiated to review cost reduction initiatives specific to underwater products; however, the issues we identified impacted more than just underwater products.