Federal Reports

The OIG investigated allegations that two Bureau of Indian Affairs (BIA) employees sold stolen BIA equipment to a contractor, and that another BIA employee provided sensitive procurement information to a contractor in exchange for kickbacks.We found no evidence to support either allegation. Regarding the first allegation, the BIA facility did not have a tracking system in place during the time of the alleged theft, so we could not determine whether BIA owned the property alleged to have been stolen. The BIA employees and the contractor denied the theft and a search of the contractor’s premises did not identify any Government property. Since the time of the alleged theft, the BIA facility has updated its property management system. Regarding the second allegation, both the BIA employee and the contractor denied the allegation of collusion and kickbacks, and we did not locate any witnesses or records to corroborate the allegation.

Our objective was to assess the efficiency of the U.S. Postal Service’s transportation consolidations of mail (loading, unloading, and trailer utilization) for long-distance Highway Contract Routes (HCR) at the Atlanta Network Distribution Center (NDC).

The Postal Service has experienced package volume growth that has created the need for increased vehicle cargo-handling capacity. Additionally, the existing fleet of LHD vehicles in service have exceeded their end-of-life projections and have ongoing operating costs that are higher than their value. Our objective was to determine whether the Postal Service’s Extended Capacity Left-Hand Drive (LHD) delivery vehicles acquisition achieved performance metrics, costs, and savings.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the VA Sierra Nevada Health Care System (the Facility) inpatient and outpatient settings. The review covered key clinical and administrative processes—Leadership and Organizational Risks; Quality, Safety, and Value; 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; 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 169 employees. The OIG noted that despite working together as a team for less than one year, the Facility leaders communicated common goals and priorities and emphasized a transparent, inclusive leadership philosophy and practice. The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics, and improvements demonstrated the leaders’ continued commitment to advance beyond the “3-Star” rating. The OIG noted findings in five of the clinical operations reviewed and issued eight 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 • Completion of required root cause analyses 2) Credentialing and Privileging • Utilization of service-specific data for Ongoing Professional Practice Evaluations 3) Environment of Care • Core members’ participation in environment of care rounds • Development and implementation of Hazard Analysis Critical Control Point Food Safety Plan • Implementation of quarterly Food Services inspections • Labeling of Food Items 4) Mental Health Care: Post-Traumatic Stress Disorder Care • Completion of Suicide Risk Assessments 5) High-Risk Processes: Central Line-Associated Bloodstream Infections • Training of Registered Nurses

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 William Jennings Bryan Dorn VA Medical Center (the 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: 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 Facility has stable executive leadership and active engagement with employees as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). The OIG’s review of accreditation organization findings, sentinel events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was actively engaged and knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the “2-Star” rating. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued eight recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are: 1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes 2) Environment of Care • Core members’ participation in environment of care rounds • Environmental cleanliness • Medical equipment safety 3) Mental Health Care • Timely completion of suicide risk assessments 4) Long-Term Care • Geriatric evaluation program performance improvement and oversight • Identification and implementation of geriatric plan of care interventions