Federal Reports

The VA Office of Inspector General (OIG) conducted this inspection to evaluate concerns related to a Virtual Pharmacy Services (VPS) pharmacist’s discontinuation of an antidepressant medication for a patient of the Minneapolis VA Health Care System, which resulted in the patient not having prescribed antidepressant medication for approximately six weeks before dying by suicide. The OIG found the VPS pharmacist did not access the patient’s electronic health record or notify the psychiatrist when discontinuing an antidepressant medication order. Although the facility granted the VPS pharmacist access to the patient’s electronic health record, the pharmacist reported not being aware of this capability. The discontinuation of the patient’s medication may have contributed to increased depressive symptoms, including suicidal ideation, in the six weeks following the patient’s scheduled completion of the medication. The OIG was unable to determine that the medication discontinuation contributed directly to the patient’s death; however, the possible worsening of the patient’s underlying depressive illness may have been a contributing factor. The OIG identified discrepancies between VPS pharmacists’ duties outlined in their functional statement and duties actually performed. VPS pharmacists’ inability to fully execute certain functions may contribute to decisions that are not fully informed and patients may not receive medications as prescribed. The VPS productivity measure of 95 prescriptions processed per hour might be an unreasonable target and may contribute to increased risk for pharmacist error. Further, Pharmacy Benefits Management leaders did not ensure VPS prescription processing was adequately monitored for accuracy. Pharmacy Benefits Management leaders failed to clearly outline program management and quality assurance monitoring objectives and processes leading to deficiencies that can contribute to adverse patient outcomes. The OIG made five recommendations to the Under Secretary for Health related to standardizing software menu options, revising functional statements and performance metrics, and establishing certain quality assurance objectives.

OIG evaluated FSIS’ controls over meat, poultry, and egg product labels to ensure FSIS’ approval of labels was accurate and supported.

We audited the Los Angeles County Development Authority’s Family Self-Sufficiency Program due to a hotline complaint (HC-2019-4215) alleging that the Authority did not use its program funds in compliance with U.S. Department of Housing and Urban Development (HUD) requirements. Our audit objectives were to determine whether the Authority met its program goals and objectives to assist eligible families in becoming self-sufficient and administered its program in compliance with HUD requirements. In addition, determine whether the hotline complaint allegations of Authority employees misappropriating program funds for personal benefit had merit.We determined that the hotline complaint had no merit. The Authority met its goals and objectives to assist its participants in becoming self-sufficient and ensured that program funds were used in compliance with HUD requirements. Specifically, the Authority ensured that it (1) maintained the minimum program size; (2) provided participants with individual training and services plans, which included specific interim and final goals; (3) monitored participants’ progress to ensure that they met their goals to become self-sufficient; (4) calculated participants’ escrow accounts accurately; and (5) used program funds for supported and eligible activities.There are no recommendations.

A Coach Cleaner in New Orleans, Louisiana, was terminated from employment on June 18, 2020, following an administrative hearing for violating company policy. Our investigation found that the employee failed to report multiple arrests and criminal convictions for drug and weapons related charges during his tenure with the company. Specifically, we found that he failed to disclose his 2017 and 2019 arrests and their subsequent convictions to the company.

A supervisor and foreman in Chicago, Illinois, were terminated from employment on June 11, 2020 and issued a written reprimand on June 18, 2020, respectively, for violating company policies. Specifically, our investigation found that the supervisor violated company policies by driving a company-owned vehicle for personal use and operated the vehicle in excess of 90 mph while using a cellular telephone without a hands-free device. In addition, the supervisor directed the foreman to use another company-owned vehicle to tow the supervisor’s personally owned vehicle.

We found, based on our review of samples of approved and rejected TPD discharge applications, that FSA appropriately approved and rejected the applications. We determined that FSA applied appropriate criteria to approve and reject individual TPD discharge applications in accordance with Federal program requirements. We also found that Nelnet generally serviced those TPD accounts throughout the TPD discharge process in accordance with Federal program requirements.2 In addition, based on our review of FSA’s processes and samples of TPD discharge applications, we determined that FSA ensured that accurate information on student loan discharges was entered into the TPD databases.Although we found that FSA appropriately approved or rejected applications, we identified design weaknesses in FSA’s control activities for the TPD discharge application review process that may negatively affect the operating efficiency and effectiveness of the process and increase the risk that FSA approves applications that are inaccurate or incomplete. In addition, we found weaknesses in FSA’s documented procedures and its quality control review for its TPD discharge application review process. We also found weaknesses in FSA’s monitoring of the TPD discharge process.