Federal Reports

The OIG conducted a focused evaluation of the quality of care delivered at the Tennessee Valley Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. The OIG also provided crime awareness briefings to 145 employees. The facility has a generally stable executive leadership to support patient safety, quality care, and other positive outcomes; however, opportunities exist to improve both patient experiences and employee attitudes towards leadership. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take significant actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the most current 1-star ranking. The OIG noted findings in five of the clinical operations reviewed and issued 15 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Ongoing Professional Practice Evaluation data review • Documentation of decisions by physician utilization management advisors (2) Medication Management: Anticoagulation Therapy Management • Patient education specific to the new anticoagulation medications (3) Coordination of Care: Inter-facility Transfers • Transfer data analysis and reporting • Patient transfer documentation • Resident supervision (4) EOC • Frequency and attendance of EOC rounds • General cleanliness • Radiology signage • Panic alarm testing • Locked mental health unit Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Related to Moderate Sedation • History and physical examinations and pre-sedation assessment components • Provision and documentation of informed consent • Clinical staff training

The VA Office of Inspector General (OIG) received an allegation regarding noncompliance with contract and Occupational Safety and Health Administration (OSHA) requirements at the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma, during the installation of a Full Facility Standby Generator. The allegation also stated that VA staff moved excavated soil using VA equipment. The OIG reviewed the contract for the generator installation valued at $8.7 million and substantiated the allegation that VA officials contributed to hazardous construction conditions. The OIG did not substantiate that VA staff or equipment was used to move the excavated soil. The contracting officer’s representative (COR) did not comply with contract requirements for approval of excavation and shoring design prior to beginning excavation, and did not perform a proper assessment of a hillside before using it to dispose of excavated soil. Furthermore, the COR accepted an excavation and shoring design with errors. The Chief, Engineering Service, did not ensure the COR had the experience to provide oversight of the excavation. VA officials terminated the contract after paying nearly $5 million. An estimated additional $17.5 million will be spent to fix problems that arose for total expected costs of $22.5 million. The OIG also substantiated the allegation that VA officials provided inadequate assurance of contractor compliance with OSHA requirements at the excavation site. The construction safety officer did not follow VA policy on the frequency of safety inspections and did not effectively implement periodic safety inspections. The contracting officer, COR, or project engineer did not delegate safety responsibilities in accordance with VA policy. As a result, the contracting officer was not notified of OSHA violations and was unable to ensure a safe environment was maintained during the contract.

An Amtrak Yard Engineer in Washington, D.C., resigned on March 20, 2018, in lieu of an administrative hearing after failing to report two prior criminal convictions in violation of various company policies.