Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the West Palm Beach VA Medical Center. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG review, the leadership team had worked together for just over two months. All positions were permanently assigned. Employee survey results identified opportunities for improvement but also reflected an environment where staff felt respected and discrimination was not tolerated. Patient survey results, while generally more positive than VHA averages, also highlighted opportunities to improve male inpatient experiences and female patients’ access to routine specialty care appointments. Executive leaders were knowledgeable about selected medical center Strategic Analytics for Improvement and Learning metrics but lacked understanding of community living center metrics.The OIG issued two recommendations for improvement in two areas:(1) Quality, Safety, and Value• Surgical work group attendance(2) High-Risk Processes• Prevention and management of disruptive behavior training

VA built the West Los Angeles VA Medical Center and other facilities on land donated more than 100 years ago to provide housing for veterans with disabilities. While the West Los Angeles Leasing Act of 2016 allows non-VA entities to use the land, all real property leases and land-use agreements must “principally benefit” veterans and their families.In a follow-up from a 2018 audit, the VA Office of Inspector General (OIG) found that VA has made little progress in implementing the housing and service enhancement goals laid out in the draft master plan that would ultimately provide housing for 1,200 veterans. As of July 2021, VA had available only 55 of the 480 housing units—11 percent of the draft master plan’s four-year target. This occurred due to required environmental impact studies, needed infrastructure upgrades, difficulties establishing a principal developer enhanced-use lease, and challenges in raising funding.Additionally, the OIG identified seven land-use agreements that did not comply with the West Los Angeles Leasing Act of 2016. While a prior 2018 audit identified two of these seven agreements, VA has not yet taken sufficient corrective action.The OIG recommended that VA implement a plan that brings the five new land-use agreements into compliance with the West Los Angeles Leasing Act of 2016, the draft master plan, and other federal laws. The OIG further recommended that VA ensure its capital asset inventory accurately reflects all land-use agreements lasting six months or longer on the West Los Angeles campus.

OIG evaluated SITC’s corrective actions from a prior audit report and the controls over the identification of internet sales of prohibited products for calendar year 2019.