Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered by the Hampton VA Medical Center (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; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health (MH) Residential Rehabilitation Treatment Program (RRTP). The OIG provided crime awareness briefings to 197 employees. The Facility had a newer executive leadership team that seemed stable, actively engaged with employees, and appeared to support patient safety and quality care. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. The OIG noted findings in all seven areas of clinical operations reviewed and issued 19 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Peer Review Committee actions • Ongoing Professional Practice Evaluation data review (2) Medication Management: Anticoagulation Therapy • Laboratory testing prior to initiating anticoagulation treatment • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Identification of receiving provider (4) EOC • EOC rounds frequency and attendance • Panic alarm testing and police response times • Clean supply storage • Locked MH unit security surveillance system functionality • MH employee and Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation • Assessment of patients’ previous adverse experiences with sedation • Physician training prior to reprivileging (6) Long-Term Care: CNH Oversight • CNH Oversight Committee meeting frequency and representation • Integration into the facility quality improvement program • Annual reviews • Social worker and nurse clinical visits (7) MH RRTP • Daily resident room inspections • Security surveillance system functionality

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OIG’s audit of grants to New York’s State Department of Environmental Conservation, Division of Fish and Wildlife, included claims totaling approximately $171 million on 19 grants that were open during the State fiscal years that ended March 31, 2015, and March 31, 2016. The audit also covered the Department’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using hunting and fishing license revenue, and reporting program income.We found that the Department complied, in general, with applicable grant accounting and regulatory requirements. The Department had not, however, reported losing control of real property purchased with grant funds and license revenue, reconciled its real property records with FWS’ real property inventory, performed a biennial equipment inventory, followed Federal requirements for subaward administration and reporting, accurately reported grant performance accomplishments at a wildlife management area, or reported barter agreement transactions on Federal Financial Reports.