Federal Reports

This report details the OIG’s healthcare inspection to assess a range of allegations regarding medication management deficiencies and potential patient safety issues associated with implementation of the new electronic health record (new EHR) at the Mann-Grandstaff VA Medical Center in Spokane, Washington.The OIG found that the new EHR implementation was deficient in numerous areas affecting medication management, including (1) data migration issues leading to inaccurate contact information and medication lists; (2) medication order processes erroneously discontinuing certain medications, permitting registered nurses to enter orders without authorization, and failing to notify providers of important prescribing information; and (3) medication reconciliation processes being impeded by incomplete medication lists that led to staff developing time-consuming workarounds, which increased risks of errors.Many of the medication management deficiencies remained unresolved during the OIG’s inspection from January to early June 2021. Although the OIG did not identify any associated patient deaths during this inspection, deployment of the new EHR without resolution of deficiencies may present risks to patient safety and affect providers’ treatment decisions.Findings can be found in two companion reports related to clinical care coordination issues after going live, concerns identified with the process for addressing “tickets” for resolving problems, and factors that contributed to deficiencies.The OIG made two recommendations to the Deputy Secretary: Ensure that substantiated and unresolved allegations are reviewed and addressed, and notify the OIG of any other medication management issues identified after the healthcare inspection. VA concurred with the first recommendation but not with the second, stating the recommendation creates a continuous reporting requirement to the OIG that prevents its closure. The OIG reminded the VA of its duty to provide this information and will close the recommendation when VA demonstrates an effective and sustainable process to identify and address patient safety issues.

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 Salem VA Medical Center in Virginia. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG inspection, the medical center’s leaders, except the Assistant Director, had worked together for over one year. Employee satisfaction survey data revealed opportunities for the Associate Director–Patient/Nursing Services to improve employee attitudes toward leaders and the workplace. Overall, results for inpatient and patient-centered medical home experience surveys were generally higher for both genders when compared to the corresponding VHA averages. However, survey results highlighted an opportunity for leaders to improve female patients’ ability to obtain urgent specialty care appointments.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were able to speak in depth about actions taken during the previous 12 months to maintain or improve organizational performance, employee satisfaction, or patient experiences.The OIG issued two recommendations for improvement in two areas:(1) Care Coordination• Monitoring and evaluation of patient transfers(2) High-Risk Processes• Disruptive behavior committee meeting attendance

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Lewis Center Main Office in Lewis Center, OH (Project Number 22-042). The Lewis Center Main Office is in the Ohio-2 District of the Central Area and services ZIP Code 43035, which serves about 24,760 people in what is considered an urban community. We judgmentally selected the Lewis Center Main Office based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.