Federal Reports

KPMG made 29 recommendations that are intended to strengthen DOI’s information security program as well as those of DOI’s bureaus and offices.

The VA Office of Inspector General (OIG) conducted an inspection at the Raymond G. Murphy VA Medical Center (facility) in Albuquerque, New Mexico, to assess allegations regarding deficiencies in the reprocessing and quality control of reusable medical devices (RMDs). The OIG also reviewed Veterans Integrated Service Network (VISN) 22 oversight of the facility Sterile Processing Service (SPS) leaders’ management of RMD reprocessing. The OIG substantiated that high-level disinfection (HLD) documentation was missing for endoscopes used in gastroenterology procedures for four patients. Three patients underwent procedures with anal manometers that lacked HLD documentation. In review of electronic health records, the OIG did not find adverse clinical outcomes for these seven patients. Patients were at risk for infection when RMDs used in patient care lacked HLD documentation. While the OIG could not determine if any RMDs were improperly cleaned prior to use, SPS leaders did not inform the Gastroenterology Service when HLD documentation was missing and precluded facility clinical staff from ensuring risks to patient safety were immediately addressed.Deficiencies in HLD quality assurance processes persisted into March 2023, despite facility leaders’ awareness of HLD findings from a May 2022 VISN audit. Specifically, SPS supervisors did not consistently complete daily quality assurance reviews of HLD documentation. The VISN failed to ensure facility leaders’ completion of action plans related to HLD findings from the VISN audit. The lack of VISN oversight resulted in delayed implementation of sustainable, corrective action, which did not occur for over a year from the original audit findings. The OIG made seven recommendations regarding VISN oversight of SPS audit findings, as well as facility identification, resolution, and quality assurance of HLD documentation and communication of SPS staff roles and responsibilities.

A former Alamo Navajo School Board member was sentenced for stealing Federal funds and receiving kickbacks for an IT services contract.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Finger Lakes Healthcare System, which includes the Bath and Canandaigua VA Medical Centers and multiple outpatient clinics in New York and Pennsylvania. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued three recommendations for improvement in three areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations - equivalent specialized training and similar privileges2. Environment of care• Environment of care inspections3. Mental health• Comprehensive Suicide Risk Evaluation completion