Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Western Massachusetts Healthcare System in Leeds. 

This evaluation focused on five key content domains:
   •    Culture
   •    Environment of care
   •    Patient safety
   •    Primary care
   •    Veteran-centered safety net

The OIG issued one recommendation for improvement in one domain:
1.    Environment of care
   •    Leaders assess storage locations outside of standard supply rooms and implement a process to ensure staff remove expired supplies

A former executive of a Chicago-area non-profit organization has pleaded guilty to a federal fraud charge for her role in misappropriating $1.8 million intended to support the charity’s work with underprivileged youth.

The OIG’s Mental Health Inspection Program (MHIP) evaluates Veterans Health Administration’s (VHA’s) continuum of mental healthcare services. This inspection focused on the inpatient care delivered at the Edward P. Boland VA Medical Center, part of the VA Central Western Massachusetts Healthcare System (facility) in Leeds.

The facility met some VHA requirements for inpatient mental health units, including providing the required amount of interdisciplinary programming for veterans and the completion of twice-yearly environment of care inspections. The inpatient unit included some aspects of a recovery-oriented physical environment, such as soft night lighting in the nurses’ station and veterans’ rooms.

Electronic health record reviews indicated most veterans were involved with the interdisciplinary treatment team in treatment planning, and veterans had documented safety plans. However, some records did not include evidence of timely suicide risk screenings, and discharge instructions were difficult to understand, lacking important details for appointment follow-up and medication management.

The facility did not have an established local mental health executive council or an interdisciplinary safety inspection team during the review period. The facility’s admission policy did not include processes for the admission of veterans on an involuntary hold. The facility leaders lacked formal processes to monitor and track compliance with involuntary commitment state laws.

The OIG identified environment of care deficiencies such as the unit’s sally port entrance doors were not synchronized; the inpatient unit had unweighted, unsecured chairs in a group room; and facility staff did not have a policy that addressed the use of a restraint chair. Additionally, many staff did not have evidence of completed environment of care or suicide prevention trainings. 

The OIG issued 16 recommendations to facility leaders. These recommendations, once addressed, may improve the quality and delivery of veteran-centered, recovery-oriented care on the inpatient mental health unit and beyond.

The National Credit Union Administration (NCUA) Office of Inspector General (OIG) conducted this self-initiated audit to assess the Central Liquidity Facility (CLF). The objectives of our audit were to determine: (1) whether the NCUA operates the CLF in accordance with relevant laws, regulations, policies, and procedures; and (2) the utilization of the CLF by credit unions covered by the temporary authority granted by the CARES Act.

Results of our audit determined the NCUA operated the CLF in accordance with applicable laws and substantially complied with regulations and its own policies and procedures. We determined the annual stock adjustment done by the CLF was not entirely done in accordance with regulations as the CLF did not receive payments for adjustments to member capital stock subscriptions no later than March 31. However, we determined the financial impact of these payments not being received by March 31 was de minimis. We also determined the CLF was being utilized as evidenced by its growth in members. While we are making no recommendations in our report to management, we are suggesting management determine whether they want to pursue any action to extend the due date beyond March 31st for the annual stock adjustment payments to the CLF.