Federal Reports

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 Captain James A. Lovell Federal Health Care Center (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: Posttraumatic 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 Facility is the only fully integrated VA-DoD medical Facility in the United States addressing the needs and expectations of active duty military, military families, and the local veteran population. The OIG noted that Facility leadership, uniquely shared between VHA and DoD, was actively engaged with employees to improve satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. The OIG identified organizational risks related to a lack of consistent risk management, quality management, and/or patient safety processes, including those associated with institutional disclosures, root cause analyses, and peer review activities that may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Director, Chief Medical Executive, and Associate Director for Facility Support. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Physician Utilization Management Advisors’ documentation of decisions • Interdisciplinary review of utilization management data (2) Credentialing and Privileging • Focused Professional Practice Evaluation process (3) Environment of Care • Environmental cleanliness and maintenance (4) Medication Management: Controlled Substances Inspection Program • Annual physical security actions

OIG data analytics identified the Arlington, VA, Main Post Office with two large inventory count discrepancies in the unit reserve stamp stock accountability. The objective of this audit was to determine whether the unit reserve stamp stock inventory was managed effectively at the Arlington, VA, Main Post Office.

OIG data analytics identified the Mesquite, TX, Main Post Office had 104 fuel transactions totaling $9,827 at risk during the period of April through June 2018 and 1,669 Voyager card fuel transactions totaling $55,016 during the April through June 2018 period. The objective was to determine whether Voyager card transactions were properly reconciled for detecting and disputing potentially fraudulent activity at the Mesquite Main Post Office.

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 Oklahoma City Health Care System (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: Posttraumatic 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 Facility had generally stable executive leadership since December 2017 and active engagement with employees as evidenced by satisfaction scores. However, opportunities exist to improve patient experiences. Although the OIG noted concern with the number of sentinel events and disclosures, Facility leaders reported reviewing each event, taking corrective actions, and developing preventive measures to improve performance. The OIG reviewed accreditation agency findings, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results and did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the “3-Star” rating. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued two recommendations that are attributable to the Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Utilization management data review (2) Long-term Care: Geriatric Evaluations • Program oversight and evaluation

Our prior reviews have found that some hospitals did not comply with Medicare coverage and documentation requirements for inpatient rehabilitation facilities (IRFs). CMS’s Comprehensive Error Rate Testing (CERT) program found that the error rate for IRFs increased, ranging from 9 percent in 2012 to a high of 62 percent in 2016. Our objective was to determine whether IRFs complied with Medicare coverage and documentation requirements for fee-for-service (FFS) claims for services provided in 2013.