Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to the care provided to a patient who was mistakenly treated with phototherapy for bed bugs and developed complications. Two days after receiving the phototherapy treatment, the patient was hospitalized for first degree (outer layer of the skin) and second degree (deeper layers of the skin) burns. Phototherapy is ordered by a dermatologist after diagnosis of a skin condition that would be responsive to treatment. Phototherapy is not indicated for the treatment of patients with bed bugs. A dermatology clinic registered nurse (RN) provided phototherapy to the patient for the treatment of bedbugs without a provider assessment and order, even though a dermatologist was available for assessment the day of treatment. Facility staff improperly attributed the need for action to its Integrated Pest Management policy that guides environmental actions. Despite an appendix to the policy that stated, “there is no specific medical treatment for bed bugs,” facility staff pursued a clinical treatment, phototherapy, for the patient. Facility leaders initiated a fact-finding review. The review’s charge letter was unclear regarding its confidential or non-confidential status. Confidential reviews may not be used as a basis for administrative action. The OIG made two recommendations to the Veterans Integrated Service Network 16 Director related to fact finding reviews conducted at the Gulf Coast Veterans Health Care System. The OIG made five recommendations to the Gulf Coast Veterans Health Care System Director related to dermatology clinic nurse practice requirements, training, and competencies; a review of the Gulf Coast Veterans Health Care System’s policy related to environmental actions following identification of bed bugs; necessary training related to the policy; and completion of Gulf Coast Veterans Health Care System’s actions recommended by an internal review.

We have performed reviews in several States in response to a congressional request concerning the number of deaths and cases of abuse of residents with developmental disabilities in group homes.Federal waivers permit States to furnish an array of home and community-based services to Medicaid beneficiaries with developmental disabilities so that they may live in community settings and avoid institutionalization. The Centers for Medicare & Medicaid Services (CMS) requires States to implement a critical incident reporting system to protect the health and welfare of Medicaid beneficiaries receiving waiver services.

This report presents the results of our self-initiated audit of Delivery and Customer Service Issues – Silverado Station, Las Vegas, NV. Our objective was to assess retail and mail delivery service on selected routes at the Silverado Station – Las Vegas, Nevada. This audit was designed to provide Postal Service management with timely information on potential delivery and customer service risks at Silverado Station.

This report presents the results of our self-initiated audit of Delivery Scanning Issues - South Station, Newark, NJ. The objective of this audit was to evaluate the delivery scanning process on select routes at the South Station. The South Station is in the Northern New Jersey District of the Northeast Area. The South Station has 19 delivery routes with 28 city carriers (23 Full Time Regular carriers and five city carrier assistants) and five clerks. We selected the South Station based on our analysis of stop-the-clock (STC) scan data from the Product Tracking and Reporting (PTR) system.

We engaged a contract audit firm to conduct an audit of the VISTA grant awarded to Conservation Legacy. The auditors found 40 percent of the VISTA projects tested were not sustained, which was similar to the finding in OIG report 18-12, VISTA Program Evaluation. In that report, the Office of Inspector General recommended the Corporation for National and Community Service (CNCS) define sustainability and improve VISTA monitoring. In response to the VISTA Evaluation and in its March 11, 2019, Management Decision, CNCS concurred with these recommendations and included the corrective actions in process or completed. Therefore, there are no recommendations in this audit report. In its response to the draft report, Conservation Legacy stated it was pleased the report did not contain findings. The grantee noted it is committed to improving the sustainability of the projects and looks forward to continuing to provide economically challenged communities with resources to help tackle pressing issues of poverty.