Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the G.V. (Sonny) Montgomery VA Medical Center. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances Inspection Program; Mental Health: 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. Four of five Facility leadership positions were filled by permanent staff for at least a year prior to the OIG’s on-site visit. The Acting Associate Director had been in place since April 2018. The OIG noted opportunities to improve employee and patient satisfaction; and the presence of organizational risk factors, as evidenced by sentinel events, disclosures, and Patient Safety Indicator data may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Although the leadership team was generally knowledgeable about selected Strategic Analytics for Improvement and Learning metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the current “2-Star” rating. The OIG noted findings in four of the clinical operations reviewed and issued 11 recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: (1) QSV • Protected peer review process (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) EOC • Storage of medical equipment and supplies • Mental health seclusion room safety • CBOC EOC rounds and medication storage and disposal • CBOC environmental cleanliness and storage requirements (4) Mental Health: Posttraumatic Stress Disorder Care • Suicide risk assessments • Diagnostic evaluations

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 Mann-Grandstaff VA Medical Center. 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: 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 executive leadership team has been working together since November 2017, when the Director was appointed. Overall, the OIG noted that employees and patients appeared satisfied with the leadership team and the care provided. Organizational leaders appeared to support patient safety and quality care. However, OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results identified a seemingly high number of institutional disclosures for this low complexity facility, which could be a potential risk factor if not reviewed and monitored. The OIG noted findings in five of the eight areas of clinical operations reviewed and issued seven recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (3) Environment of Care • Biohazardous waste storage • Panic alarm testing and response time documentation • Emergency Operations Plan annual review (4) Long-term Care: Geriatric Evaluations • Program oversight (5) High-risk Processes: Central Line-associated Bloodstream Infections • Staff education

Inadequate oversight at both the Centers for Medicare & Medicaid Services (CMS) and the State Medicaid agency (State agency) level created vulnerabilities in State agencies' use of random moment timestudies (RMTS) as a basis to allocate and claim Federal Medicaid reimbursement for costs associated with school-based administrative activities and health services. Previous OIG reviews of 10 State agencies that used RMTS to allocate costs for school district administrative claiming (SDAC) and school-based health services (SBHS) determined that the State agencies claimed a total of $435.4 million in SDAC and SBHS costs that were not in accordance with Federal requirements and guidance.

BCFS Health and Human Services Did Not Always Comply With Federal and State Requirements Related to the Health and Safety of Unaccompanied Alien Children

Inadequate oversight at both the Centers for Medicare & Medicaid Services (CMS) and the State Medicaid agency (State agency) level created vulnerabilities in State agencies' use of random moment timestudies (RMTS) as a basis to allocate and claim Federal Medicaid reimbursement for costs associated with school-based administrative activities and health services. Previous OIG reviews of 10 State agencies that used RMTS to allocate costs for school district administrative claiming (SDAC) and school-based health services (SBHS) determined that the State agencies claimed a total of $435.4 million in SDAC and SBHS costs that were not in accordance with Federal requirements and guidance.

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Intensity-modulated radiation therapy (IMRT) is an advanced type of radiation procedure used to treat difficult-to-reach tumors. National Government Services, Inc. (NGS), the Medicare Administrative Contractor responsible for processing Medicare payments for outpatient services in Jurisdictions 6 and K, incorrectly paid hospitals for IMRT services provided to nearly all of the beneficiaries associated with our review.