Federal Reports

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 Captain James A. Lovell Federal Health Care Center and outpatient clinics in Illinois and Wisconsin. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. At the time of this inspection, the healthcare center’s leaders had been working together for four months. Employee satisfaction survey results revealed opportunities for the Chief Medical Executive and VA Chief Nurse Executive to improve employees’ feelings of “moral distress” at work. Patient experience surveys indicated general satisfaction; however, female veteran scores were less favorable. The leaders were knowledgeable within their scopes of responsibility about Strategic Analytics for Improvement and Learning data and should continue to take action to sustain and improve performance. The OIG issued 27 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Committee processes • Utilization Management processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluations • Provider exit reviews (3) Environment of Care • Environmental cleanliness • Privacy and security (4) Medication Management • Quality measure oversight (5) Mental Health • Suicide prevention training (6) Women’s Health • Primary Care Mental Health Integration services • Community-based outpatient clinic women’s health primary care providers • Women Veterans Health Committee membership • Quality data monitoring (7) High-Risk Processes • Standard operating procedures • Annual risk analysis • Airflow testing • Eyewash station testing • Environmental cleanliness • Equipment storage and tracking • Staff training

Delivery System Reform Incentive Payment (DSRIP) Program payments are incentive payments made to hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality and cost-effectiveness of care, and increase the health of patients and families served. These incentive payments have significantly increased funding to providers for their efforts related to the quality of services. Texas made DSRIP Program payments totaling almost $10 billion for 5 years.Our objective was to determine whether Texas used permissible funds as the State share of DSRIP Program payments.

DHS components used inconsistent processes for administrative forfeitures under the Civil Asset Forfeiture Reform Act of 2000 (CAFRA). Specifically, we found inconsistencies among DHS components regarding the forms used to notify property owners and the process for responding to claims. Further, CBP inappropriately used waivers to extend deadlines for responding to claims. We recommended DHS implement a department-wide structure to oversee component forfeiture activities across DHS by designating an office at headquarters for this role. Additionally, DHS should develop Department-wide policies and procedures, as well as review component policies, to ensure forfeiture processes and practices are consistent. We made two recommendations to improve oversight across DHS and provide consistent processes for handling administrative forfeitures. DHS concurred with recommendation two, which we consider resolved and open, but did not concur with recommendation one, which is unresolved and open.

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 Clement J. Zablocki VA Medical Center and multiple outpatient clinics in Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The medical center’s executive leadership team had been working together for over two years. Employee satisfaction survey results revealed opportunities for the Deputy Director and Assistant Director to decrease employee feelings of moral distress at work. Patient experience survey data noted satisfaction with care. Survey results for males and females were generally more favorable than VHA results nationally. The review of accreditation findings did not identify any substantial organizational risk factors. The OIG identified significant concerns with sentinel events identification. Executive leaders were generally able to speak knowledgeably about actions taken during the previous 12 months to maintain or improve performance, and were knowledgeable within their scopes of responsibilities about Strategic Analytics for Improvement and Learning data. The OIG issued 28 recommendations for improvement in seven areas:(1) Quality, Safety, and Value • Committee processes • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Safety and cleanliness • Information security (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up (6) Women’s Health • Gynecologic care coverage • Committee membership • Quality data • Women veteran program manager position (7) High-Risk Processes • Annual risk analysis • Environmental cleanliness • Equipment storage

o Since 2017, DHS has continued to make progress in meeting its Digital Accountability and Transparency Act of 2014 (DATA Act) reporting requirements, but challenges remain. To enable more effective tracking of Federal spending, DHS must continue to take action to accurately align its budgetary data with the President’s budget, reduce award misalignments across DATA Act files, improve the timeliness of financial assistance reporting, implement and use government-wide data standards, and address risks to data quality. Without these actions, DHS will continue to experience challenges in meeting its goal of achieving the highest possible data quality for submission to USAspending.gov. We made five recommendations to help strengthen DHS’ controls for ensuring complete, accurate, and timely spending data. The Department concurred with all five recommendations.