Federal Reports

The Office of Inspector General examined NASA’s management of its 20‐year,$484 million cooperative agreement with the NSBRI to advance the Agency’sbiomedical research efforts.

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 Wilkes-Barre 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; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 205 employees.The facility has stable executive leadership, specifically with the assignment of a permanent Facility Director. 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. However, OIG noted opportunities to improve both employee satisfaction and patient experiences. The senior leadership team seemed knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 3-star SAIL rating.OIG noted findings in two of the six areas of clinical operations reviewed and issued three recommendations that are attributable to the Chief of Staff, Nurse Executive, and Associate Director. The identified areas with deficiencies are:(1) Environment of Care • Participation on environment of care rounds• Respiratory environment in the Community Living Center units(2) Long-Term Care: Community Nursing Home Oversight• Cyclical clinical visits

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Alexandria VA Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; Long-Term Care: Community Nursing Home Oversight; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 105 employees.The facility has stable executive leaders who support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. The executive leaders appear to have active engagement with employees but need to continue efforts to improve patient experience scores. The leaders also seemed knowledgeable about selected Strategic Analytics for Improvement and Leaning (SAIL) metrics but should make significant efforts to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 2-star SAIL rating.OIG noted findings in five of the six areas of clinical operations reviewed and issued nine recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value• Review of Ongoing Professional Practice Evaluation data(2) Medication Management: Anticoagulation Therapy• Patient education specific for newly prescribed anticoagulant medications(3) Environment of Care• Participation on environment of care rounds• Safe and clean environment in all patient care areas• Locked mental health unit employee and Interdisciplinary Safety Inspection Team training(4) Long-Term Care: Community Nursing Home Oversight• Community Nursing Home Oversight Committee representation • Cyclical clinical visits(5) Post-Traumatic Stress Disorder Care• Suicide risk assessments• Referral for diagnostic evaluations

The Administration for Children and Families (ACF) had a process in place to ensure that Head Start grantees took corrective action on A-133 audit findings. Head Start grantees are required to have Single Audits conducted in accordance with Office of Management and Budget Circular A 133 (also known as A-133 audits) for fiscal years beginning before December 26, 2014. However, for Region II Head Start grantees that submitted audit reports to the Federal Audit Clearinghouse, ACF did not always resolve recurring audit findings in accordance with Federal requirements and ACF policies and procedures. Specifically, ACF did not issue letters transmitting management decisions for six of the eight audit reports we reviewed within 6 months after receiving the reports. In addition, although ACF provided the grantees with letters stating that the corrective actions planned or taken should prevent recurrence of the findings, ACF did not establish specific dates for grantees to correct deficiencies noted in the audit reports. Finally, ACF did not always follow up with grantees to ensure that they actually took corrective actions to resolve audit findings. The prompt resolution of audit findings helps ensure that Federal funds are effectively and efficiently used to carry out the activities for which they were authorized.

The Health Resources and Services Administration (HRSA) awarded Henry J. Austin Health Center, Inc. (HJAHC), a not-for-profit organization, $8.3 million in grant funds through several Community Health Center Program grants to provide comprehensive primary care services in the Trenton, New Jersey, area. Of this amount, $281,000 was to support certain activities (i.e., one-time equipment purchases).