Federal Reports

This year, we highlighted the underlying causes of the Department's persistent management and performance challenges, which hamper efforts to accomplish the homeland security mission efficiently and effectively. The challenges are two-fold. First, Department leadership must commit itself to ensuring DHS operates more as a single entity rather than a collection of components. The lack of progress in reinforcing a unity of effort translates to a missed opportunity for greater effectiveness. Second, Department leadership must establish and enforce a strong internal control environment typical of a more mature organization. The current environment of relatively weak internal controls affects all aspects of the Department’s mission, from border protection to immigration enforcement and from protection against terrorist attacks and natural disasters to cybersecurity.

OIG conducted an inspection in response to Senator James Inhofe’s request to evaluate clinical, supervisory, and administrative practices at the Oklahoma City VA Health Care System (System), Oklahoma City, OK. We also evaluated the System Director’s concerns and coordinated parts of this review with The Joint Commission. Our comprehensive review identified multiple program areas, processes, and operations needing improvement. The root cause for many of these issues was poor and unstable leadership at a number of levels, most notably in the Director position. Without strong and effective leadership, an inattentive and apathetic organizational culture evolved that allowed problems to arise and persist. It was only after new leadership was installed in May 2016 that the culture improved and necessary changes took place. We made 24 recommendations.

OIG conducted a healthcare inspection to address concerns received from Congressman Jim Costa in 2014 regarding allegations from an anonymous complainant of Emergency Department (ED)-boarded patients’ length of stay, poor inpatient flow, and nurse staffing shortages at the Central California VA Health Care System (system), Fresno, CA. An anonymous complainant with similar allegations contacted the OIG Hotline in December 2013, July 2014, and February 2015. We requested system leaders respond to the allegations and in their May 2015 response, they acknowledged issues with ED-boarded patients’ length of stay, inpatient flow, and registered nurse staffing, and implemented an improvement plan with 15 actions. In January 2016, we conducted a review of system leaders’ progress after 6 months (July 1, 2015 through December 31, 2015) of implementing their action plans. We found that they did not implement 1 of the 15 actions: system leaders had not established written protocols to identify a process to transfer ED-boarded patients to available VA and non-VA facilities when acute inpatient beds were unavailable. In addition, the system’s policy that addressed the designated location for ED patient overflow did not identify criteria for ED-boarded patients who could be transferred to the Community Living Center. In the course of our review, we identified a patient whose adverse outcome illustrated many of the challenges associated with ED-boarded patients who need to be transferred due to the lack of available inpatient beds. The patient died after a prolonged transport on the maximal dose of a medication generally used in critical care. We made eight recommendations.