Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered by randomly selected Veterans Health Administration (VHA) facilities. The inspection covers key processes associated with promoting quality care, including Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Posttraumatic Stress Disorder; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The Office of Inspector General (OIG) noted that 85 percent of leaders were assigned permanently at the 51 VA facilities visited from October 2017 through September 2018. These facility leaders generally appeared engaged in supporting quality, felt supported by VISN leaders, were aware of improvement efforts for employee and patient satisfaction, and actively addressed Joint Commission and OIG recommendations for improvement. Sixteen of the surveyed facilities with a “1-” or “2-star” Strategic Analytics for Improvement and Learning (SAIL) star rating had significant opportunities for improvement, and facilities with higher SAIL star ratings had fewer OIG recommendations for improvement. The OIG issued 16 recommendations for improvement: (1) Quality, Safety, and Value • Implementation of peer review improvement actions • Physician utilization management advisors’ inpatient stay reviews • Interdisciplinary utilization management data reviews • Feedback for root cause analysis actions (2) Credentialing and Privileging • Reporting of focused professional practice evaluations (FPPEs) to an appropriate committee of the medical staff • Clearly delineated timeframes in FPPEs • Service-specific data in ongoing professional practice evaluations (OPPEs) • Specialty-specific elements in selected specialty providers’ OPPEs (3) Environment of Care • Environmental cleanliness • Panic alarms testing • Floor cushioning in mental health unit seclusion rooms • Emergency operations plan/processes (4) Controlled Substances Inspections • Correction of deficiencies from annual physical security surveys • One-day reconciliation of stock between pharmacy and dispensing areas • Monthly controlled substances inspections (5) Geriatric evaluation program oversight/evaluation

Lamont Brown, a resident of Brooklyn, NY, pleaded guilty in U.S. District Court, Eastern District of New York, on October 10, 2019, to conspiracy to commit wire fraud, for his involvement in an Amtrak eVoucher scheme. Brown and his co-conspirators used stolen credit card information to make unauthorized purchases of Amtrak tickets and then cancelled or exchanged those tickets for eVouchers. Subsequently, they sold the fraudulently obtained eVouchers on the internet. Brown’s sentencing is pending.

At the request of the Tennessee Valley Authority (TVA), we performed an audit of costs paid by TVA to AECOM Energy and Construction, Inc. (AECOM) for engineering services under Contract No. 8273. The contract provided for TVA to compensate AECOM for work on either a cost reimbursable or fixed price basis. Our audit objective was to determine if the costs were billed in accordance with the terms and conditions of the contract. Our audit scope included about $21.6 million in costs paid by TVA from January 1, 2016, to April 30, 2018.In summary, we determined AECOM overbilled TVA $287,346, including (1) $235,437 in labor costs, (2) $27,010 in subcontractor costs, (3) $11,742 in fee, (4) $9,682 in travel costs, <br> (5) $2,050 in materials costs, and (6) $1,425 in fixed price costs. Additionally, we noted issues with TVA's contract administration including (1) inadequate oversight of the fee evaluation process, (2) markup rates not included in the contract, and (3) activity on closed purchase orders. (Summary Only)

The DOL-OIG Highlights is part of our ongoing commitment to ensure that all stakeholders are fully and timely apprised of the OIG’s efforts.

Quarterly Summary Memorandum to the Lead Inspector General, Department of Defense