Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that the Associate Director for Patient Care Services endangered patient safety by placing an unqualified leader as the Acting Chief of Sterile Processing Services (SPS) at the facility. The OIG did not substantiate that the detailed Acting Chief endangered patient safety. Facility leaders based incumbent selection on leadership experience and the individual’s workload, which the detailed Acting Chief had. The OIG reviewed issue briefs submitted during the time of the detail and found no patients were harmed. Facility leaders failed to comply with a 2009 memorandum requiring complexity Level 1 and 2 facilities to have an SPS assistant chief position. Facility leaders failed to ensure a reliable process was in place for identifying changes in manufacturer’s instructions. Moreover, from 2011 to 2017, SPS staff reassembled the arthroscopes and cystoscopes prior to sterilization contrary to the manufacturer’s instructions. However, once the issue was identified, the facility, Veterans Integrated Service Network, and Veterans Health Administration leaders took appropriate action to address the problem, evaluated associated risk, consulted with the required experts, and decided based on their risk analysis that patient exposure risk was minimal and no further actions were needed. A possible reason for the facility’s failure to identify the change to the manufacturer’s instructions was a series of acting and permanent chiefs of SPS. This lack of stable SPS leadership also contributed to the failure to review and update SPS staff competencies. The OIG made three recommendations relating to staffing, compliance with manufacturer’s instructions, and competencies.

The TLH Lake Jackson Station is in the Gulf Atlantic District of the Southern Area. OIG data analysis identified this unit had a 159 percent increase in account identifier code 594 Vehicle Fuel and Oil Expense Paid Locally between fiscal year (FY) 2019, Quarter (Q) 4, and FY 2020, Q1, from $1,470 to $3,811, respectively. In addition, $5,281 represented 39 percent of overall expenses paid in the Gulf Atlantic District for the same timeframe. Furthermore, there were no payments made in FY 2018, Q4, or FY 2019, Q1 (same period last year). Our objective was to determine whether local payments for fuel and oil issued at the TLH Lake Jackson Station were valid, processed timely, and properly supported.

This report presents the results of our self-initiated audit of facility conditions at the Belmar (owned), Normandy Beach (leased), and Spring Lake (leased) post offices in the South Jersey District. The Postal Service is required to maintain a safe and healthy environment for both employees and customers in accordance with its internal policies and procedures1 and Occupational Safety and Health Administration (OSHA) safety laws. Our objective was to determine if Postal Service management is adhering to building maintenance, safety and security standards, and employee working condition requirements at post offices.