Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Eastern Colorado Health Care System (facility) in Aurora to assess allegations that a lack of care coordination and a lack of hepatocellular carcinoma (HCC) surveillance led to a delay in a patient being diagnosed with HCC.The OIG substantiated that a lack of care coordination occurred when the patient transferred between primary care providers, which contributed to a lack of HCC surveillance and varices monitoring. Facility leaders have an unwritten expectation that primary care providers conduct a thorough historical review of the patient’s electronic health record starting with the most recent annual note; however, the OIG found that not all of the patient’s providers conducted historical reviews, but instead focused on current issues and problems identified by the patient.The OIG determined that the patient’s providers, and facility providers in general, did not maintain an accurate problem list, creating another missed opportunity to conduct necessary HCC surveillance. Furthermore, facility providers did not consistently comply with the recommended HCC surveillance for other patients with a similar diagnosis. Surveillance, if done correctly, could have led to an earlier diagnosis of HCC in the patient.The OIG made six recommendations to the Facility Director related to care coordination, developing and updating patient problem lists, reviewing an established patient’s medical record, conducting a clinical review of the care of the patients discussed in the report and determining if adverse events occurred, and ensuring that patients receive HCC surveillance and varices monitoring.

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 VA Hudson Valley Health Care System in Montrose, New York. The inspection covered key clinical and administrative processes that are associated with promoting quality care, focusing on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the review, the healthcare system’s leaders had worked together for one year, with the Director, Associate Director for Patient Care Services, and Chief of Staff serving since May 2020, December 2015, and August 2019, respectively. The Associate Director was appointed in December 2020 and also covered the open assistant director position. Employee survey scores for the healthcare system were lower than the VHA averages, although scores for most leaders were generally similar to or higher than VHA and healthcare system averages. Outpatient satisfaction survey results generally reflected higher care ratings than VHA averages. However, they also highlighted opportunities to improve patient perceptions of inpatient care, as well as outpatient providers and access to outpatient services. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors but position turnover in the Quality Management Service was noted as an area of vulnerability. Executive leaders were very knowledgeable about selected data used in Strategic Analytics for Improvement and Learning measures.The OIG issued seven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Protected peer review process(2) Care Coordination• Inter-facility transfer policy and documentation• Nurse-to-nurse communication(3) High Risk Processes• Staff training

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Beaverton Main Post Office in Beaverton, OR (Project Number 22-031). The Beaverton Main Post Office is in the Idaho-Montana-Oregon District of the WestPac Area. The post office services ZIP Codes 97005 and 97008. There are about 54,806 people living in these ZIP Codes, which are considered urban communities. We chose the Beaverton Main Post Office based on the number of stop-the-clock3 (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

At the request of the Tennessee Valley Authority's (TVA) Supply Chain, we examined the cost proposal submitted by a company for transmission construction services. Our examination objective was to determine if the cost proposal was fairly stated for a planned 5-year, $25 million contract.In our opinion, the company's cost proposal was overstated. We found the proposed labor markup rates, for recovery of indirect costs, were overstated compared to recent actual costs. We estimated TVA could avoid about $783,000 over the planned $25 million contract by negotiating revised labor markup rates to more accurately reflect the company's recent actual costs. (Summary Only)