Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding management and patient safety at the Community Living Center (CLC). The complainant alleged that CLC managers discouraged incident reporting, coached staff on how to talk to residents or the resident’s personal representative following adverse events, and made staff fearful of retaliation for reporting concerns. Allegations also included inadequate staffing and oversight for resident care, mismanagement of laboratory specimens and medication delivery, and regulation of environmental temperatures. The OIG identified additional concerns related to employee dissatisfaction and laboratory staff’s failures to notify healthcare providers of critical laboratory results. The OIG did not substantiate managers discouraged incident reporting, inappropriately coached staff, or made staff fearful of retaliation for reporting concerns. System leaders acknowledged persistent staff dissatisfaction could have affected resident care. Although actions were taken to improve operations, unresolved issues related to employee satisfaction persisted. However, the OIG concluded the system maintained adequate nurse and provider staffing for resident care. The system exceeded Veterans Health Administration requirements for evaluating nurse staffing. Laboratory specimen handling led to falsely elevated potassium results and unnecessary treatment. Laboratory staff failed to thoroughly investigate and resolve the cause of inaccurate results. Additionally, the OIG found providers were inconsistently notified of critical laboratory results. CLC medication deliveries were also delayed. Although the causes for delays were undetermined, the lack of an on-site pharmacy likely contributed. During the inspection, the System Director announced plans for a pharmacy at the CLC. The OIG did not substantiate additional allegations of an inability to regulate environmental temperatures. Facility and engineering staff provided timely responses to periodic temperature issues. The OIG made five recommendations to the System Director related to CLC employee satisfaction, laboratory specimen handling, investigation of laboratory concerns, critical laboratory result notifications, and medication delivery.

The VA Office of Inspector General (OIG) initiated an inspection to assess allegations regarding deficiencies in nursing care in the Community Living Center (CLC). The OIG substantiated the allegation that a CLC nurse improperly left medication in a patient’s room. The inspectors conducted an observation of 35 patient rooms and did not find any medications left in rooms or hallways other than two creams on a bedside table. While the OIG was unable to determine the validity of many of the allegations due to a lack of information from the complainants or within the patients’ electronic health records, there were nursing documentation deficiencies identified in the CLC related to the allegations. These deficiencies included inconsistent documentation of compliance with medication order instructions, pain assessments and pain management plans, fall prevention and post-fall assessments, fall prevention measures (including inconsistent answering of call bells), and nursing wound prevention processes. The OIG made other findings not specifically related to the allegations, including failure to follow the approval procedure for a new hourly rounding form, ineffective implementation of a new procedure for nurse rounding, incomplete fact-finding reviews, inconsistent facility committee documentation, and inoperable CLC safety equipment. A contributing factor for the identified deficiencies was an outdated facility staffing policy that did not follow all Veterans Health Administration (VHA) staffing methodology requirements for calculating adequate levels. The OIG made nine recommendations addressing nursing processes including documentation of fall prevention and post-fall assessments, placement and use of call bells, wound prevention processes, medication administration, and pain assessments and pain management plans; compliance of rounding forms to facility procedures; establishment of fact-finding review processes; leadership committees’ tracking and monitoring of issues to resolution; checks that safety equipment used for transfers is operational; and staffing policy consistency with VHA requirements.

Our objective was to determine whether the Social Security Administration (SSA) had adequate controls over resolving potentially fraudulent Internet Claims (iClaim) identified by SSA's Office of Anti-Fraud Programs (OAFP).

The VA Office of Inspector General (OIG) conducted this audit to determine whether veterans received accurate compensation when hospitalized by VA for more than 21 days for service-connected disabilities. The OIG also examined whether claims processors met requirements to document the competency of veterans to handle VA funds who were admitted for service-connected mental health conditions. Veterans hospitalized for more than 21 days are entitled to receive temporary increases to 100 percent in tax-free disability compensation. Veterans Benefits Administration (VBA) employees process the compensation adjustments based on hospital admission and discharge reports. Staff’s failure to properly start or end the temporary compensation increases can lead to underpayments or overpayments. The OIG estimated VARO employees did not adjust or incorrectly adjusted disability compensation benefits in about 2,500 of the estimated 5,800 cases eligible for adjustments, creating an estimated $8 million in improper payments in calendar year 2018. The OIG estimated 1,900 cases did not have competency determinations documented for service-connected mental health conditions. The deficiencies occurred because employees did not consistently generate required reports and maintain report logs. Managers also provided ineffective oversight. As a result, veterans risked not receiving the proper benefits. Employees who processed benefit adjustments also lacked proficiency. They lacked sufficient ongoing experience and training to maintain requisite knowledge. This is also why employees were unclear on the requirement to document the relevant competency of veterans admitted for service-connected mental health conditions. The OIG made six recommendations to the under secretary for benefits, including ensuring proper admission and discharge reporting, as well as making certain that employees receive refresher training when needed to properly process temporary benefit adjustments for eligible veterans.