Federal Reports

We visited 14 facilities in the Great Lakes Area, and reviewed all 26,051 accidents, including all 95 serious accidents for FYs 2016 and 2017. We also reviewed employee participation in the Counseling At Risk Employees (CARE) program, which was established to engage employees in accident prevention using accident statistics, root cause analyses, and action plans. Our objective was to determine whether the Postal Service adhered to safety policies and procedures related to accidents in the Great Lakes Area.

We selected to audit the Mid-Carolinas District because it had the second highest extra service costs for fiscal year (FY) 2017 of $6.5 million with a total number of over 12,400 recorded extra trips. We reviewed a statistical sample of 190 PS Form 5429 (e5429), Certification of Exceptional Contract Service Performed representing 84 HCR routes and over 3,900 extra HCR trips in FY 2017. We also conducted site visits or interviews to review the extra trips process at the Processing and Distribution Centers (P&DCs) in Asheville, Charlotte, and Fayetteville, NC, and Greenville, SC. Our objective was to assess the effectiveness of the Postal Service’s extra trip process for Highway Contract Routes (HCRs) in the Mid-Carolinas District.

Effective in 2018, the Medicare program changed the way it sets payment rates for clinical diagnostic laboratory (lab) tests. CMS replaced payment rates with new rates based on charges in the private health care market. This is the first reform in 3 decades to Medicare's payment system for lab tests. As part of the same legislation reforming Medicare's payment system, Congress mandated that OIG monitor Medicare payments for lab tests and the implementation and effect of the new payment system for those tests. This data brief provides the fourth set of annual baseline analyses of the top 25 lab tests.

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The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Roseburg VA Health Care System (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The Facility has been and continues to be in transition. Three of the four executive leaders were new to their positions, and two were in temporary assignments. Facility challenges including ineffective leadership, toxic culture, personnel practices, and improper admission practices have been reported by media and were the subject of recent internal and external evaluations. The OIG reviewed accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors. However, the OIG identified concerns with hydromorphone (pain medication) shortages, gaps in provider privileging processes, and inadequate tracking and monitoring of On-demand supplies. The senior leadership team appeared aware of the magnitude of the challenges and were taking action to restore a culture of trust, increase employee and patient satisfaction, and improve the quality of care and efficiency metrics contributing to the “1-Star” rating. The OIG noted findings in three of the seven areas of clinical operations reviewed and issued seven recommendations that are attributable to the Interim Director, Acting Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations processes (2) Environment of Care • Storage of cleaning solutions in food preparation areas (3) Medication Management: CS Inspection Program • CS monthly inspections • CS reconciliation