Federal Reports

ARC awarded the grant to provide SCC funding support to expand its industrial technology and automotive (the Advanced Manufacturing and Automotive Technology) training programs to it new Cherokee County Campus (CCC).

The grant provided ARC funding to support a project entitled "Wallace State Community College Winston County Works" The project was designed to provide basic skills, workplace skills and technical training to residents in Winston County

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to address concerns regarding illicit fentanyl use and urine drug screening (UDS) practices at the Domiciliary Residential Rehabilitation Treatment Program (DRRTP), Bath VA Medical Center, New York. The Veterans Health Administration does not require treatment programs to routinely test for illicit drugs, such as fentanyl, that are trending in the community. In response to incidents involving fentanyl abuse by DRRTP residents, facility leaders amended the UDS policy to include an extended panel UDS that tests for fentanyl. Residents were randomly selected each day for an extended panel UDS. However, the extended panel UDS was processed by a non-VA laboratory with a turnaround time that compromised the timeliness of clinical intervention and overdose prevention. Facility leaders took additional actions to increase the identification of fentanyl use, including the tracking of positive UDS results. The OIG determined that the facility’s fiscal year 2017 positive UDS tracking data was inaccurate. Staff stated there was confusion interpreting the thresholds and some UDS results were incorrectly recorded. To assist DRRTP staff in identifying residents with a history of opioid use and a high-risk for suicide patient record flag, facility leaders implemented a practice of placing color-coded stickers on resident doors. The practice was discussed in the facility’s Mental Health Council meeting; however, key staff reported being unaware of its use for residents at high risk for suicide. OIG staff also found that Domiciliary Assistants did not have sufficient personal protective equipment or training to safely conduct contraband searches of residents’ rooms and belongings. The OIG made eight recommendations related to drug screening guidelines, regional drug abuse identification, timely laboratory turnaround times and result notifications, positive UDS tracking and monitoring, UDS results interpretation training, color-coded sticker practices, and contraband search personal protective equipment and training.

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 Battle Creek VA Medical Center (Facility). 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; Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. Two of four Facility leadership positions were filled by interim staff at the time of the OIG’s on-site visit. On April 1, 2018, the Chief of Staff assumed the Acting Director role, and the Chief of Dentistry took over responsibilities as the Acting Chief of Staff. The OIG noted that Facility leaders appear to be actively engaged with employees and were working to improve inpatient satisfaction scores. Organizational leaders support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to achieve and maintain positive perceptions of the Facility through active stakeholder engagement). The OIG did not identify any substantial organizational risk factors. Three of the four leaders were knowledgeable while the Acting Chief of Staff was still becoming familiar with selected Strategic Analytics for Improvement and Learning (SAIL) metrics due to the limited time in the role. The leaders should take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current “2-Star” rating. The OIG noted findings in two of the clinical operations reviewed and issued three recommendations that are attributable to the Acting Director and Acting Chief of Staff. The identified areas with deficiencies are: (1) QSV • Required utilization management reviews (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Senators Jon Tester and Sherrod Brown to review the care of a patient who fell to his death from a second-story window at the Chillicothe VA Medical Center (Facility), Ohio. At the request of Senator Brown, the OIG also assessed whether the Facility provided grief counseling. The OIG substantiated adequate security and safety measures were not in place and confirmed external windows on the inpatient medicine unit were not secured shut or limited in width of opening as required by Veterans Health Administration policy. The OIG did not substantiate the patient failed to receive an appropriate level of care. The patient had medical and mental health conditions and was managed by both medical and mental health providers on a medical unit. The patient was under special observation status (the patient was to be within the special observer’s eye sight at all times). The special observer was unable to keep the patient under visual observation when the patient entered the bathroom, locked the door, and climbed out the window. The OIG determined that Facility leaders failed to ensure that staff who worked on the unit received required training and competency checks to maintain adherence to Facility policies. The Facility offered grief counseling to the patient’s available family and staff. The OIG found Facility’s attempt to provide an institutional disclosure was inadequate as the Facility did not disclose all significant facts to a family member and did not attempt to locate the patient’s adult child. The OIG made four recommendations related to securing windows in all patient care areas, monitoring compliance with the Special Observation policy and mental health staff training requirements, and conferring with the Office of Chief Counsel concerning family notification of the patient’s death.

The VA Office of Inspector General (OIG) reviewed the Wilmington Health Care Center (HCC) in North Carolina in response to a request from Congressman Walter B. Jones, who asked the OIG to determine whether selecting the Wilmington airport site for the HCC was in the best interest of taxpayers. He also asked the OIG to review the offers to develop the Wilmington HCC to determine whether VA officials used appropriate procedures. The OIG determined the selection of the Wilmington airport site was not in the taxpayers' best interest. VA’s Office of Construction and Facilities Management (CFM) changed its requirements, paid more than the appraised value, and used a flawed two-step process. As a result, VA will pay $2.35 million more than fair market rent over the 20-year lease. This occurred because CFM leadership lacked effective oversight of the lease. CFM has since implemented several policies and procedures negating the need for the OIG to make recommendations on some conditions reported. Specifically, CFM established a policy office and made progress in issuing formal policies and procedures; finalized its handbook, which includes oversight procedures for CFM’s leasing processes; issued official policy and procedures related to the two-step process; and implemented policies and procedures for maintaining lease documentation and transferring that documentation between CFM personnel. The OIG did recommend that the Executive Director for CFM establish a formal policy for transferring contract files when transferring responsibilities to a different contracting officer. Because CFM was unable to provide information to the OIG on all the offers for the development of Wilmington HCC, the OIG was unable to determine whether CFM used appropriate procedures during the selection and award process of the $69 million lease.