Federal Reports

The VA Office of Inspector General (OIG) evaluated the quality of care at the Wilmington VA Medical Center. This included reviews of key processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care (EOC); Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home (CNH) Oversight; and Management of Disruptive/Violent Behavior. OIG provided crime awareness briefings to 84 employees.OIG identified certain system weaknesses in EOC Committee meeting minutes; general safety; Sterile Processing Service (SPS) employee competencies; hemodialysis unit infection prevention; anticoagulation processes and employee competencies; transfer data and documentation; point-of-care testing actions; CNH oversight, clinical visits, and policies; and management of disruptive/violent behavior policy, committee representation, and employee training.As a result of the findings, OIG could not gain reasonable assurance that:(1) EOC minutes track actions taken for deficiencies until closed.(2) Community based outpatient clinic (CBOC) fire extinguishers are inspected monthly, and CBOC information technology network room logs contain access documentation.(3) SPS employees complete annual competencies.(4) Hemodialysis unit employees wear gloves when handling patient equipment.(5) Clinicians obtain required laboratory testing prior to initiating anticoagulants and have documented competency to manage anticoagulation therapy patients.(6) The facility collects and reports data on transfers out and includes required elements in transfer documentation.(7) The facility takes and documents all required actions in response to glucose point-of-care testing results.(8) The facility oversees the CNH program and performs cyclical reviews of care provided.(9) The facility’s disruptive behavior policy reflects current practice, members attend committee meetings, and employees are trained to reduce and prevent disruptive behaviors.OIG made recommendations for improvement in the following six reviews: (1) EOC, (2) Medication Management, (3) Coordination of Care, (4) Diagnostic Care, (5) CNH Oversight, and (6) Management of Disruptive/Violent Behavior.

OIG conducted a healthcare inspection to assess allegations made by confidential complainants regarding quality of care and other concerns at the Captain James A. Lovell Federal Health Care Center (FHCC), North Chicago, IL. We substantiated the Home Based Primary Care program’s Joint Commission accreditation status was “threatened” after a March 2015 FHCC accreditation survey; however, in August 2015, the Joint Commission determined the program complied with accreditation standards.We substantiated a Community Living Center patient who fell had an inaccurately low Morse Fall Scale assignment and incomplete Morse Fall Scale Notes. We substantiated that Community Living Center patient falls increased during fiscal year (FY) 2014; however, facility leadership recognized the issue and completed an action plan, which led to a decrease in patient falls in FY 2015.We substantiated the Emergency Department (ED) was left unattended by a qualified physician when ED physicians left the ED to perform emergency airway management in other FHCC care areas. We substantiated the ED did not have clerical staff support on weekends and most weekdays during the dayshift; however, this did not conflict with Veterans Health Administration policy and did not negatively affect delivery of patient care. We did not substantiate the ED length of stay for admitted patients was long or that ED transfer rates were high. We substantiated nurses did not consistently follow proper hand-hygiene practices. We substantiated primary care providers referred Navy recruits to the ED for non-emergent care needs; however, we determined the practice was permitted to ensure recruits were ready for deployment. We did not substantiate FHCC staff mishandled the suicides of two individuals. We did not substantiate the medical/surgical unit length of stay was long. We did not substantiate the Associate Director of Inpatient Services lacked the required education and experience to qualify for the position.We made three recommendations.

We determined that although a complainant alleged there were systemic security challenges in the Office of Intelligence and Analysis (OIA), there were few documented security incidents over the past 5 years, all of which OIA addressed with corrective actions. Further, OIA has improved the effectiveness of its Field Intelligence Division and the Field Intelligence Officers by hiring qualified, experienced intelligence professionals and implementing clear policies and procedures, but it could enhance officer training. OIA is also addressing weaknesses in coordination among its watches and perceived delays in intelligence reporting. We made two recommendations to improve the effectiveness of OIA operations; the Transportation Security Administration (TSA) concurred with both recommendations.