Federal Reports

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding quality of care issues in two Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated Patient A died at the facility after choking on food, but found insufficient evidence to attribute the cause of the choking to the lack of nurse staffing. The OIG substantiated the facility operator called the wrong code, leading to multiple responders, role confusion, and a delay in transporting Patient A to the Emergency Department. The OIG did not substantiate managers misrepresented the cause of death as cardiac arrest. OIG inspectors found inconsistent emergency medical response policies, post-code debriefings, and medical oversight and determined Patient A’s case warranted additional facility review. The evidence was insufficient for the OIG to substantiate or not substantiate whether patients were regularly left unsupervised while eating. The OIG did not substantiate one CLC lacked security due to malfunctioning door locks. The OIG substantiated a lack of consistent documentation of rounds but was unable to ascertain if this condition reflected an absence of completed rounds and decreased unit security. The OIG was unable to substantiate or not substantiate a lack of staff vigilance. The OIG substantiated Patient B’s wrists were bound together by a palm protector strap but did not find evidence to suggest an intentional act done by staff due to a lack of available nursing staff. The OIG did not substantiate that CLC nursing managers were often unavailable and failed to provide adequate response to unit issues. The OIG made eight recommendations to the Facility Director and one recommendation to the Veterans Integrated Service Network Director related to emergency medical response processes and policies, CLC meal staffing and delivery processes, safety rounds, and reviews of Patient A’s care.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding inadequate nurse staffing that affected quality of care in the Community Living Centers (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that nursing leaders were aware of staffing shortages in the CLCs, and the OIG confirmed the use of float staff and overtime. However, due to variables that contribute to the delivery of safe patient care, OIG inspectors were not able to substantiate or not substantiate that the use of float staff and overtime placed residents at a higher risk for adverse events. The OIG found the Facility failed to consider or utilize alterative staffing. The OIG found a lack of CLC nurse staffing due in part to a delay in filling vacant positions and a lack of approval to increase staff. In addition, OIG inspectors’ review of overtime data indicated that the overtime funding exceeded the cost associated with filling the vacant positions. The OIG substantiated that registered nurses assigned to administrative roles were utilized to provide nursing care in the CLCs. The OIG inspectors found no evidence of deficiencies or indications that the administrative nurses performed work outside of the registered nurse position description. The OIG substantiated that previous Facility leaders pressured CLC managers to accept admissions when nurse staffing was inadequate to provide expected levels of care for additional residents. However, CLC nurse managers reported improvement since August 2017 with the new Facility leadership team. The OIG substantiated that the CLCs were closed to admissions at times. However, OIG inspectors did not substantiate that residents were transferred to acute care inpatient units due to lack of CLC staffing. The OIG made three recommendations related to CLC nurse staffing and recruitment, alternative staffing, and overtime management.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding a patient’s abuse and neglect in a community living center (CLC) at the Northport VA Medical Center, New York. The OIG substantiated that a patient who died at the facility fell while living in a facility CLC and required surgery for a hip fracture sustained during the fall. The OIG did not substantiate that the patient’s fall was caused by inadequate fall precautions or that the patient’s death was caused by abuse or neglect. The OIG substantiated that the patient did not receive anticoagulation injections to prevent blood clots following surgery for hip fracture per facility protocol. The OIG did not substantiate that the failure to receive three of the four doses of anticoagulation medication during the hospital stay contributed to the patient’s death. The OIG was unable to substantiate or not substantiate that a staff member who performed one-to-one observation of the patient failed to provide proper observation during the shift when the patient died, because the OIG was unable to resolve discrepancies between facility documentation and staff interviews. The OIG did not substantiate that the CLC Nurse Manager received complaints about staff behaviors that negatively impacted patient care and failed to take corrective action. The OIG did not substantiate that facility leaders or managers tried to cover up the circumstances surrounding the patient’s death. However, the OIG determined that the missed anticoagulation medication doses were not addressed in the facility’s quality management review of the patient’s care. The OIG made three recommendations related to reviewing the accuracy of 24-Hour Observation Flow Sheets, conducting an updated quality management review of the patient’s case, and consulting with the Office of General Counsel about missed anticoagulation doses and institutional disclosure to the patient’s family.

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 Veterans Health Care System of the Ozarks (Facility). 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 Care: 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 OIG also provided crime awareness briefings to 125 employees. Although two of the Facility’s four executive leaders were in interim positions during the OIG’s on-site visit, the leaders had worked to support efforts related to patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Access metrics that are likely contributing to the “4-Star” rating. The OIG noted findings in five of the eight areas of clinical operations reviewed and issued six recommendations that are attributable to the Facility Director, Chief of Staff, and Interim Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of UM data (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (3) Environment of Care • Environment of Care rounds participation (4) Medication Management: Controlled Substances Inspection Program • CS Coordinator position description • Controlled substances order verification (5) Women’s Health: Mammography Results and Follow-Up • Linkage of mammography results to radiology order

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Northport VA Medical Center (Facility). The review covered key 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 (CS) Inspection Program; Mental Health Care: Post-Traumatic 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 current Director and the Associate Director were permanently assigned in June 2017. The former Chief of Staff and Associate Director for Patient Care Services were assigned to positions outside the Facility in August 2017, and the positions have since been filled by interim appointees. Further, opportunities appear to exist for the Director and Associate Director to provide a workplace environment where employees feel safe to bring forth issues or ethical concerns. The lack of consistent leadership oversight of quality improvement activities may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and monitored. The OIG noted findings in five of the clinical operations reviewed and issued 11 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Interdisciplinary utilization management data reviews • Implementation of root cause analysis actions and provision of feedback • Facility Leaders’ review of annual patient safety report (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) EOC • EOC rounds frequency • Pest management program • Safe and clean environment • Medical equipment safety inspection process • Mental Health seclusion room safety (4) Medication Management: CS Inspection Program • Electronic access for performing and monitoring CS balance adjustments (5) Long-Term Care: Geriatric Evaluations • Performance improvement oversight

The OIG’s data analysis identified Raleigh, NC, Capitol Station had local purchases totaling $8,240, or 27 percent of all local purchases in the Greensboro District, for the period January 1 through March 31, 2018. It is unusual for one office to have such a high percentage of local purchases as it relates to other offices in the same district. The objective was to determine whether local purchases and payments were valid and properly supported at the Raleigh, NC, Capitol Station.

We reviewed eight recommendations (Recommendations 1 and 3 – 9) presented in our August 2015 audit report U.S. Department of the Interior’s Climate Science Centers, to verify that the U.S. Geological Survey has implemented them.We confirmed that all eight recommendations have been resolved and implemented.

We reviewed documentation provided to support the closure of a recommendation from a 2007 audit of the U.S. Department of the Interior’s use of cooperative agreements.Based on our review, we do not agree that the recommendation is resolved and implemented. We have requested that the Office of Financial Management reinstate the recommendation and take appropriate follow-up action for resolution.

We audited the costs claimed by the Missouri State Department of Conservation under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. The audit included claims totaling approximately $68.3 million on 39 grants that were open during the State fiscal years that ended June 30, 2014, and June 30, 2015. The audit also covered the Department’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using hunting and fishing license revenue and reporting program income.We questioned costs totaling $2,813,979 due to financial management system errors, improper drawdowns, unreported program income, unsupported subaward claims, and unallowable indirect costs. In addition, we determined that the Department potentially diverted $30,500 in license revenue in a real property trade and did not comply with Federal and State subaward requirements.The FWS agreed with our 16 recommendations, and it will work with the Department to implement corrective actions.