Federal Reports

An Amtrak car inspector based in New York, New York, violated company policies by engaging in outside employment as a bus operator; providing security services at night clubs, lounges, and bars; and working as a bouncer while on a medical leave of absence. The employee was on a medical leave of absence from the company since November 8, 2015, and had not returned to work. On March 6, 2024, after his corporate trial and in accordance with his union agreement, the employee forfeited his seniority and is considered out of service.

The objective of the audit is to express an opinion on whether the Commission’s financial statements are presented fairly, in all material respects, in accordance with U.S. generally accepted accounting principles.

This report was revised on October 17, 2024, to correct a sentence on page 12, which provided information that contained a minor, factual error. The error was not significant to the findings and audit conclusion.

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 outpatient settings of the Manchester VA Medical Center, which includes multiple outpatient clinics in New Hampshire. 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 six recommendations for improvement in three areas:1. Medical staff privileging• Medical Executive Council reviews of professional practice evaluations• Equivalent specialized training and similar privileges• Veterans Integrated Service Network oversight2. Environment of care• Inspections• Clean and safe patient areas3. Mental health• Comprehensive Suicide Risk Evaluation completion

The VA Office of Inspector General (OIG) substantiated allegations from January 2022 that employees did not properly reprocess reusable medical equipment (RME) within the facility’s Sterile Processing Service (SPS). Facility leaders halted all endoscope usage, as well as stopped surgeries and procedures requiring RME, until an investigation was completed.The OIG identified multiple issues that contributed to SPS deficiencies, including unaddressed, previously-identified issues within SPS, such as the failure to implement CensiTrac Instrument Tracking System, SPS standard operating procedures (SOPs) being out of date and not accessible to staff, competency training being inadequate and ineffective, failure to control traffic in the sterile area that potentially impacted the integrity of RME, and the negative impact of interim and acting leaders within SPS.In April 2022, the facility had potentially harmful, abnormal critical water test results, which led to another halting of all RME reprocessing. The OIG found that leaders delayed addressing consistently abnormal testing results within SPS.The OIG made two recommendations to the VISN Director related to reviewing the facility’s SPS water management program and ensuring the VISN SPS Management Board reviews critical water testing results.The OIG made seven recommendations to the Facility Director related to ensuring that the SPS chief conducts comprehensive staff competency assessments for reprocessing RME; the CensiTrac Instrument Tracking System is fully implemented and staff are trained in its use; SPS maintains a safe and clean environment in all areas where RME processing is performed; a plan is developed for remediation of the location of the training room adjacent to SPS’s clean storage area; all clinic areas have or share a designated soiled utility storage room; SOPs for all RME are developed and disseminated; and the facility Water Working Group submits critical water test results to the VISN.