Federal Reports

On March 26, 2020, the VA Office of Inspector General (OIG) published its first COVID-19-focused report, OIG Inspection of Veterans Health Administration’s COVID-19 Screening and Pandemic Readiness. In that report, the OIG evaluated how the Veterans Health Administration (VHA) was preparing facilities to meet anticipated rising demands. This report outlines VHA’s continued response to the pandemic and provides VHA leaders’ descriptions of the evolving challenges they faced in caring for veterans and potentially nonveteran patients as well. The OIG engaged leaders from 70 selected facilities in discussions about patient-care services provided from March 11, 2020, through June 15, 2020. The discussions covered the management of urgent and emergent care, the adequacy of equipment and supplies, testing capabilities, Community Living Center (nursing home) admissions and discharges, testing protocols, and the engagement of community healthcare partners. Discussions also detailed Veterans Integrated Service Network leaders’ involvement in, and overall support of, facility operations. Finally, the OIG provided VHA leaders the opportunity to comment on plans to manage anticipated COVID-19 surges. Overall, this report highlights a multitude of actions taken by VHA, VISN, and facility leaders to maintain operations during a national emergency. With the uncertainty of timing and magnitude of possible recurrent outbreaks, this review presented strategies that various facilities put into place over the past several months that will hopefully promote discussion and consideration of lessons learned and best practices among facility and community healthcare leaders.

According to the Securing Our Agriculture and Food Act (SAFA), the program should provide oversight, lead policy initiatives, and coordinate with DHS components and Federal agencies. However, the Countering Weapons of Mass Destruction Office (CWMD) has not yet carried out a program to meet SAFA’s requirements. This occurred because CWMD believes it does not have clearly defined authority from the Secretary to carry out the requirements of the SAFA. In addition, since its establishment in December 2017, CWMD has not prioritized SAFA requirements but instead has focused its resources on other mission areas. As a result, CWMD has limited awareness of DHS’ ongoing efforts and cannot ensure it is adequately prepared to respond to a terrorist attack against the Nation’s food, agriculture, or veterinary systems. We made three recommendations to DHS’ CWMD to improve oversight, policy initiatives, and coordination of the Department’s efforts to protect the Nation’s food, agriculture, and veterinary systems.

We contracted this audit with Cotton & Company LLP, which found that FEMA did not ensure Lee County, Florida (the County) established and implemented policies, procedures, and practices to ensure it accounted for and expended PA program grant funds awarded to disaster areas in accordance with Federal regulations and FEMA guidance. Specifically, the County requested FEMA funding for $994,425 in unsupported force account labor, equipment, and materials; was unable to provide supporting documentation for $16,210 in costs incurred to operate an emergency shelter; did not maintain adequate documentation to support $267,452 in costs incurred for road repair services; did not include all required provisions in its contracts to obtain disaster recovery services related to Hurricane Irma; and had not evaluated the risk of subrecipients’ noncompliance with Federal requirements, obtained subrecipient audit reports, or developed plans for monitoring subrecipients. We made nine recommendations that, when implemented, should improve Lee County, Florida’s management of FEMA Public Assistance funds. FEMA concurred with all nine recommendations.

The OIG investigated an allegation that several minority-owned and small disadvantaged (8a) businesses may have coordinated their respective proposals to gain an unfair advantage in awards related to six contracts for technical support services at the U.S. Geological Survey (USGS).We found that these companies did not conspire to manipulate the bidding process as alleged. We found that the companies used the same consulting company to draft their respective proposals, which contained nearly identical language. The USGS ultimately did not accept any of the proposals.This is a summary of an investigative report we issued to the USGS Director.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Marion VA Medical Center and outpatient clinics in Illinois, Indiana, and Kentucky. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The executive leadership team had been working together for 17 months. Patient experience surveys indicated that patients appeared satisfied with their care. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. The leadership team, specifically the Chief of Staff and Associate Director for Patient Care Services, had opportunities to improve their knowledge within their scopes of responsibility about Strategic Analytics for Improvement and Learning data and should continue to take actions to sustain and improve performance. The OIG issued 29 recommendations for improvement in eight areas: (1) Quality, Safety, and Value • Quality management activities • Utilization management processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review forms (3) Environment of Care • Infection prevention procedures • Health information protection (4) Medication Management • Pain screening • Risk assessment • Urine drug testing • Informed consent • Patient follow-up • Pain Management Committee activities (5) Mental Health • Safety plans • Staff training (6) Care Coordination • Treatment notes (7) Women’s Health • Required staffing • Access to care and emergency contraceptives • Women Veterans Health Committee membership (8) High-Risk Processes • Required administrative processes • Staff training