Federal Reports

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 VA New York Harbor Healthcare System (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; Mental Health (MH) Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 135 employees.The facility has generally stable executive leadership with demonstrated cohesiveness and active engagement with employees and patients. Organizational leaders support patient safety, quality care, and other positive outcomes. 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.OIG noted findings in five of the clinical operations reviewed and issued 14 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) QSV • Review of ongoing professional practice evaluation data(2) Medication Management: Anticoagulation Therapy• Collection and reporting of quality assurance data• Patient education specific for newly prescribed anticoagulant medications• Employee competency assessments(3) Coordination of Care: Inter-Facility Transfers• Transfer data analyzing and reporting• Documentation of acute patient transfers to other facilities• Communication with accepting facility(4) EOC• EOC rounds attendance• Panic alarm in the locked MH unit• Risk assessment of locked MH unit electric or mechanical beds• MH Interdisciplinary Safety Inspection Team training(5) High-Risk Processes: Moderate Sedation• Reporting and trending of reversal agents and adverse events• Performance of history and physical examinations and pre-sedation assessments• Documentation of informed consent

OIG investigated allegations that the United Mine Workers of America Health and Retirement Funds (UMWAF) was not adhering to Federal law and regulations concerning three federally supported health benefit plans. According to the allegations, the UMWAF enrolled beneficiaries in the combined benefit fund (CBF) after the enrollment cutoff date and inflated the beneficiary numbers by retaining deceased beneficiaries in its records. The UMWAF reportedly also provided legal advice to a coal company during bankruptcy proceedings and failed to pursue recovery of other coal companies’ delinquent benefit plan premiums. Lastly, the UMWAF allegedly falsified enrollment documents so that beneficiaries would qualify for Federal support.We found that the UMWAF enrolled 1,909 beneficiaries into the CBF after the enrollment cutoff date and paid this population an estimated $96 million in benefits. After we initiated our investigation, however, the DOI Office of the Solicitor concluded that there was conflicting authority on this issue. The Office of Surface Mining Reclamation and Enforcement (OSMRE) will review beneficiary lists with this in mind before completing the fiscal year 2018 transfer requests. We could not determine if the UMWAF inflated beneficiary numbers by retaining deceased beneficiaries, because it did not provide detailed lists to the Government during funding requests.We also found no evidence that the UMWAF provided legal advice to a coal company during its bankruptcy proceedings, that the UMWAF failed to pursue delinquent coal operator premiums, and that the UMWAF falsified enrollment documents. We presented our findings to the U.S. Attorney’s Office for the District of Columbia, which declined prosecution.