Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Jesse Brown VA Medical Center and multiple outpatient clinics in Illinois and Indiana. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 one vacancy in its five key positions. The Medical Center Director had served in an acting capacity for two weeks, and the chief of staff position had been filled for three months. Survey results indicated opportunities to improve employee satisfaction. Patient survey results indicated overall satisfaction. The OIG did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about Strategic Analytics for Improvement and Learning measures and actions taken during the previous 12 months to maintain or improve performance. The OIG issued 22 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews • State licensing board reporting (3) Medication Management • Behavior risk assessments • Concurrent medication therapy • Urine drug testing • Informed consent • Patient follow-up • Pain Committee (4) Mental Health • Patient follow-up • Suicide safety plans • Suicide prevention training (5) Care Coordination • Multidisciplinary committee (6) Women’s Health • Women’s health primary care providers • Women Veterans Health Committee (7) High-Risk Processes • Standard operating procedures • Annual risk analysis • Competency assessments

The Office of the Inspector General conducted a review of the Watts Bar Nuclear Plant (WBN) Site Security (SS) organization to identify factors that could impact WBN SS's organizational effectiveness. Our report identified strengths that positively affected WBN SS related to (1) organizational alignment, (2) positive interactions within WBN SS, (3) first-line management support, and (4) positive ethical culture. We also identified risks that could impact the effectiveness of WBN SS to achieve its responsibilities in support of the Nuclear vision and TVA mission. These risks included (1) communication deficiencies, (2) safety concerns, (3) perceptions of inadequate staffing, (4) reporting of performance data, and (5) ineffective relationships with support organizations.

Plant load agreements are special arrangements between the U.S. Postal Service and certain commercial mailers. Mailers interested in establishing a plant load agreement must already have a Postal Service-approved detached mail unit (DMU) at their mailer facility, wherein a Postal Service clerk is on-site performing mail verification, acceptance, dispatch, and other related functions. Mail is then transported from the DMU to a Postal Service facility for acceptance and processing. Our objective was to assess the effectiveness of plant load agreements in the Santa Ana District. We selected this district based on volume and revenue declines from fiscal year (FY) 2018 to FY 2019, totaling 190 million pieces (22 percent) and $37.5 million (18 percent).

During fiscal year (FY) 2019, we issued 32 audit reports related to financial controls at Postal Service retail units. We identified inconsistencies with Postal Service policies for performing financial transactions. The purpose of this report is to bring attention to these issues and make recommendations for corrective action. Our objective was to assess current refund and local purchases and payments policies for retail units and to determine if policies were consistent.

The United States has been grappling with the opioid crisis for several years. In 2018, nearly 47,000 opioid-related overdose deaths occurred in the United States. OIG has been tracking opioid use in Medicare Part D since 2016. In particular, OIG has identified beneficiaries at serious risk of opioid misuse or overdose and prescribers with questionable opioid prescribing for these beneficiaries.