Federal Reports

In November 2015, we reported that the Federal Emergency Management Agency’s (FEMA) information technology (IT) management approach did not adequately address technology planning, governance, and system support challenges to effectively support its mission. We issued five recommendations to the FEMA Chief Information Officer (CIO) aimed at improving the agency’s management of IT.1 Specifically, we recommended the CIO finalize key planning documents related to IT modernization; execute against those planning documents; fully implement an IT governance board; improve integration and functionality of existing systems; and implement agency-wide acquisition, development, and operation and maintenance standards.

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 Jonathan M. Wainwright Memorial 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); Medication Management: Anticoagulation Therapy; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health Residential Rehabilitation Treatment Program. The OIG also provided crime awareness briefings to 92 employees. Due to past leadership and organizational failures, the facility and its leaders are in a state of transition and face a challenging task of improving the organizational culture. The leaders spoke enthusiastically of ongoing efforts to rebuild workforce and patient trust and engagement, boost employee and patient satisfaction, achieve leadership stability, and improve organizational performance. These actions included actively engaging with and involving employees at all levels and developing an infrastructure with key personnel that will support and sustain organizational transformation. The OIG noted findings in four areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) QSV • Senior-level committee for QSV functions • Annual completion of required root cause analyses (2) Medication Management: Anticoagulation Therapy • Analysis and reporting of quality assurance data • Patient education specific for newly prescribed anticoagulant medications • Laboratory tests completion prior to initiating anticoagulant medications • Staff competency assessments (3) EOC • Frequency of and participation in EOC rounds (4) Long-Term Care: CNH Oversight • Multi-disciplinary participation in Oversight Committee • Cyclical clinical visits

Four ticket agents resigned in February and March 2018, prior to their administrative hearings, for stealing money from their cash drawers at Amtrak’s Los Angeles Union Station. Our investigation determined that three of the employees would wait until train conductors electronically scanned passengers’ tickets and would then reset the ticket’s status as if it had not been scanned at all.

The Office of Inspector General examined NASA’s internal controls to guard against fraud and misuse by employees in its purchase and travel card programs.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered by the Hampton 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); Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health (MH) Residential Rehabilitation Treatment Program (RRTP). The OIG provided crime awareness briefings to 197 employees. The Facility had a newer executive leadership team that seemed stable, actively engaged with employees, and appeared to support patient safety and quality care. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. The OIG noted findings in all seven areas of clinical operations reviewed and issued 19 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Peer Review Committee actions • Ongoing Professional Practice Evaluation data review (2) Medication Management: Anticoagulation Therapy • Laboratory testing prior to initiating anticoagulation treatment • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Identification of receiving provider (4) EOC • EOC rounds frequency and attendance • Panic alarm testing and police response times • Clean supply storage • Locked MH unit security surveillance system functionality • MH employee and Interdisciplinary Safety Inspection Team training (5) High-Risk Processes: Moderate Sedation • Assessment of patients’ previous adverse experiences with sedation • Physician training prior to reprivileging (6) Long-Term Care: CNH Oversight • CNH Oversight Committee meeting frequency and representation • Integration into the facility quality improvement program • Annual reviews • Social worker and nurse clinical visits (7) MH RRTP • Daily resident room inspections • Security surveillance system functionality