Federal Reports

The NCUA OIG conducted this self-initiated audit to assess the NCUA’s joint examination process with state supervisory authorities. The objectives of our audit were to determine: 1) whether the NCUA provided shared oversight of federally insured state-chartered credit unions (FISCUs) to assess their condition and address material risks that could negatively affect the Share Insurance Fund; and 2) whether the NCUA effectively monitored FISCUs using off-site monitoring tools and joint oversight processes with state supervisory authorities (SSAs).

Gladys Perez, Coach Cleaner, Los Angeles, California, was terminated from employment on December 5, 2019, following an administrative hearing for violating company policy. Our investigation found that Perez participated in a health care fraud scheme in which Amtrak’s health care plan was billed for acupuncture and other services that were not actually provided. On October 10, 2019, Perez signed a pretrial diversion letter agreement, which was accepted in U.S. District Court for the Central District of California, wherein she admitted to committing two counts of health care fraud in furtherance of the scheme to defraud the company’s health plan.

This review provides a focused evaluation of the quality of care delivered at the Coatesville VA Medical Center, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The executive leadership team appeared stable and engaged as they worked to sustain and improve employee and patient engagement and satisfaction. Review of accreditation organizational findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the Executive Leadership Board was not following actions until completion. The leaders were aware of Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to maintain and improve performance contributing to the SAIL “5-star” and CLC “2-star” quality ratings. The OIG issued 16 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Implementation of corrective actions from root cause analyses (2) Medical Staff Privileging • Medical Executive Board review/recommendation of privileging actions (3) Environment of Care • Environmental cleanliness • Inventory of resources and assets for emergency management • Generator testing (4) Controlled Substances Inspections • Inspector appointments and competencies • Verification of controlled substance orders (5) Mental Health • Military sexual trauma training (6) Geriatric Care • Patient/caregiver understanding of medication education (7) Women’s Health • Women Veterans Health Committee membership (8) Emergency Departments and Urgent Care Centers (UCC) • Waiver for 24-hour operations • Registered nurse staffing • Availability of support services (9) Incidental Finding • Ambulance transportation of emergent patients to UCC

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Chalmers P. Wylie Ambulatory Care Center covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership had been working together for about nine months. Employee satisfaction and patient experience scores were similar to or better than the VHA average. Organizational leaders appeared to support efforts related to safety and quality care; however, there were concerns related to wrong-site /wrong-procedures and appropriate and timely institutional disclosures. The leaders were knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance of measures contributing to the current SAIL ratings. The OIG issued 13 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Implementation of peer review improvement actions • Completion of Root Cause Analyses • Committee review of resuscitative episodes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Medical Executive Board consideration of OPPEs in recommendation to continue privileges (3) Controlled Substances Inspections • Quarterly review of controlled substances inspections reports (4) Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Abnormal results notification (7) Incidental • Anesthesia documentation of controlled substance administration