Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 5: VA Capitol Health Care Network in Linthicum, Maryland, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The executive leaders, who had worked together since August 2020, had spent much of their time and efforts on improving care and leadership at the Louis A. Johnson VA Medical Center following an OIG criminal investigation of a VA nursing assistant who was convicted and sentenced for the murder of seven veterans. Leaders reported taking actions such as ensuring staff completed Morbidity and Mortality reviews, evaluating quality of care through an Administrative Investigation Board, and monitoring hiring and background check processes.Selected survey scores related to employee satisfaction with VISN leaders generally exceeded VHA averages; however, the Deputy Network Director’s servant leadership score was lower than the VHA average. VISN patient experience survey scores were similar to VHA averages, except for inpatient care satisfaction at selected VISN 5 facilities. The OIG identified potential risk factors including mental health wait times at selected facilities over 20 days, higher rates of clinical vacancies, and challenges with facility hiring support and retention of human resources staff. The Network Director, Chief Medical Officer, and Quality Management Officer/Chief Nursing Officer had opportunities to improve oversight of facilities’ quality, safety, and value; care coordination; and high-risk processes.The OIG issued one recommendation for improvement:(1) Medical Staff Credentialing• Physician credentials review process

The Office of Inspector General (OIG) conducted an inspection to assess a safety concern with the new electronic health record (EHR) that resulted in patient harm. The OIG found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of to the intended location. Veterans Health Administration (VHA) identified and ranked safety concerns with the new EHR. In December 2021, VHA assessed the risk of the unknown queue as “major severity,” “frequently occurring,” and “very difficult to detect.” As such VHA recognized immediate mitigation was needed. Oracle Cerner failed to inform VA end-users of the existence of the unknown queue and put the burden on VHA to mitigate the problem.Beginning in June 2021, VHA staff spent substantial hours to complete clinical reviews to assess patient risk and harm related to the unknown queue and found that the new EHR’s delivery of orders to the unknown queue caused 149 patient harm events.In late 2021,VHA staff provided the Deputy Secretary and the Executive Director for VA’s EHR modernization effort with information on the unknown queue safety concern and identified patient harm. Each facility that goes live with the new EHR will require an ongoing commitment from facility staff to monitor and address the new EHR’s unknown queue. Cerner and VHA took actions to minimize orders being routed to the unknown queue. However, after finding over 200 orders in the unknown queue in May 2022, the OIG has concerns with the effectiveness of Cerner’s plan to mitigate the safety risk.

The objective was to determine the extent to which the Public Assistance Alternative Procedures (PAAP) met the goals set forth in Section 428 of the Stafford Act and did so in accordance with legislation and FEMA guidelines since the alternate procedures were made available in 2013.

We determined whether FSIS’ actions taken in response to complaints of sexual misconduct and harassment in the workplace, received October 1, 2019, through May 31, 2021, were in accordance with Departmental and agency policy.