Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection to evaluate clinical and administrative concerns involving a specific podiatrist at the Lexington Veterans Affairs Medical Center (Facility), Kentucky. The OIG did not substantiate that Podiatrist A performed inadequate podiatry examinations and did not provide comprehensive care. Podiatrist A’s documentation was consistent with and generally met Veterans Health Administration criteria. No evidence of poor or inadequate care was found. The OIG could not substantiate that Podiatrist A misrepresented some patients’ clinical statuses by documenting inaccurately in the electronic health record. Direct observation at the time of the encounter would have been required to determine whether a provider is misrepresenting patients’ presenting conditions. The OIG could not substantiate that Podiatrist A “disappeared” from the clinic and did not see patients timely. No recent concerns about Podiatrist A’s attendance were identified. At the time of its unannounced observations, the OIG found that Podiatrist A was in the clinic and saw patients within the scheduled and allotted time frames. The OIG could not substantiate that Podiatrist A’s “last-minute” sick leave notification was intentional. The OIG did not substantiate that leaders ignored the issues rather than fix the problems. Leaders and managers conducted internal reviews and took actions when indicated. Through interviews and document reviews, OIG staff learned of unprofessional conduct and significant discord among Podiatry Department staff. The OIG determined that the culture of mistrust within the Podiatry Department had eroded professionalism and has the potential to place patients at risk for adverse outcomes. The OIG made one recommendation to the Facility Director to develop a clear action plan to resolve the Podiatry Department work environment issues and monitor compliance to ensure patient safety.

The U.S. Department of Labor, Office of Inspector General’s Investigations Newsletter highlights selected investigative accomplishments of our office for the period from February 1 to March 31, 2018.

This memorandum communicates the results of my determination of the Federal Trade Commission's (FTC) compliance with applicable provisions of the Improper Payments Elimination and Recovery Act of 2010, in accordance with Section 3(b) of Public Law 111-204, Improper Payments Elimination and Recovery Act of 2010.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Puget Sound Health Care System (the Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 75 employees. The Facility’s leadership team is relatively new. With the exception of the Acting Assistant Director, the executive leaders have been working together as a team since October 2017. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although OIG’s review of survey data suggested generally satisfied employees, opportunities appear to exist to improve outpatient experiences. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance likely contributing to the two-star ranking. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Director, Chief of Staff, Deputy Director, and Assistant Director. The identified areas with deficiencies are: (1) Environment of Care • Environment of care rounds attendance • Medical equipment safety • Infection Prevention Committee’s discussion and documentation of on-going construction activities • Temperature monitoring in dry food storage areas (2) Medication Management: Controlled Substances Inspection Program • Reconciliation of controlled substances dispensing and return of stock