Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection, in response to a notification that a hospitalized patient died by suicide and a subsequent request from House Veterans Affairs Committee Chairman Mark Takano, to review the circumstances of the death. Inpatient death by suicide is an event that is largely preventable. The OIG determined the patient received reasonable care during the admission. The patient was appropriately screened for suicide risk, provided medication management, placed on close observation status, and had on-going assessments, interventions, and a discharge plan. However, the facility failed to abate identified safety hazards on the unit. Patient safety cameras were nonoperational and 15 minute patient safety rounds policy lacked clear guidance and expectations for staff. The facility did not meet Veterans Health Administration (VHA) requirements for staffing an Interdisciplinary Safety Inspection Team or training staff regarding the Mental Health Environment of Care Checklist (MHEOCC). The OIG found a lack of oversight by both the VHA MHEOCC Work Group and Veterans Integrated Service Network (VISN) 8. The OIG also found facility leaders lacked awareness and failed to educate themselves on patient safety requirements regarding the mental health unit. While the OIG team determined the facility responded promptly to the adverse patient event and was in the process of implementing improvement actions, facility leaders and managers only started to respond aggressively to long-standing deficient conditions after a sentinel event occurred. The OIG made one recommendation to the Under Secretary for Health, one recommendation to the VISN Director, and nine recommendations to the Facility Director related to leaders’ responsibilities regarding mental health, environment of care, and patient safety; MHEOCC training; risk mitigation; facility policy regarding patient safety and law enforcement cameras on the locked mental health unit; 15-minute safety rounding policy; and staff training.

The Office of the Inspector General (OIG) contracted with ATC Group Services LLC (ATC), to conduct a review of groundwater monitoring activities at the Kingston Fossil Plant Peninsula Disposal Unit to determine the quality of the program and adherence to regulatory standards. ATC stated that in their opinion, monitoring activities performed at TVA Kingston Fossil Plant Peninsula Disposal Unit are in adherence with guidelines for the Environmental Protection Agency and the Tennessee Department of Environment and Conservation. Furthermore, ATC stated the work performed appears to be of high quality and does not likely result in any discrepancies for the program.

Our objective was to assess the Postal Service’s employee background screening process to determine whether individuals selected for employment are suitable to maintain the safety and security of the mail and uphold public trust in the Postal Service.

Our objective was to evaluate the HVAC PM process at mail processing facilities. We reviewed a statistical sample of 118 facilities to assess HVAC PM performance for a two-year period from September 1, 2016, through October 31, 2018.

Our audit objective was to determine whether the U.S. Patent and Trademark Office monetary awards were (a) granted in compliance with the relevant award criteria and (b) sufficiently documented. Our audit scope included awards related to patent examiners’ performance and productivity ratings in fiscal year 2016.

In 2012, we issued a report to the Centers for Medicare & Medicaid Services (CMS) indicating that during 2009, Medicare Part D paid for prescription drugs that likely should have been paid for by hospice organizations under the Medicare Part A hospice benefit. We matched Part A and Part D data to identify occurrences when Part D paid for drugs for beneficiaries who were receiving hospice care at the same time. We conducted this audit to follow up and expand on the previous audit.

The Postal Service uses Account Identifier Code (AIC) 526, Refund Spoiled/Unused Customer Meter Stamps, to record refunds of spoiled/unused postage meter stamps from customer postage meters. OIG data analytics identified that the New Brighton Branch recorded $50,125 to AIC 526 from April 1 to September 30, 2018. Meter revenue refunds at the New Brighton Branch accounted for 28 percent of all refunds processed under AIC 526 in the Northland District for the same timeframe, making the New Brighton Branch the facility with the most refunds in the Northland District for the scope period. The objective of this audit was to determine whether meter revenue refunds were properly issued, supported, and processed.