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 Nebraska-Western Iowa Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value; Environment of Care (EOC); Medication Management: Controlled Substances Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 45 employees. The facility has generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the facility through active stakeholder engagement). The 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. The senior leadership team was knowledgeable about selected SAIL metrics likely contributing to the most current 5-star ranking. The OIG noted findings in five areas of clinical operations reviewed and issued seven recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Associate Director. The identified areas with deficiencies are: (1) EOC • EOC rounds attendance • Infection prevention/control goals and identification of risks (2) Medication Management: Controlled Substances Inspection Program • One-day reconciliations during inspections • Pharmacy 72-hour inventories (3) Long-Term Care: Geriatric Evaluations • Program oversight • Nursing assessments (4) Women’s Health: Mammography Results • Communication of test results to patients

The VA Office of Inspector General (OIG) evaluated controls over the adjudication of background investigations at VA medical facilities to determine whether adjudication actions were timely completed and reliably recorded. The OIG found VA did not effectively manage the personnel suitability program to ensure investigations were completed for facility staff and estimated that about 6,200 required investigations were not initiated. Adjudicators had not been reviewing investigations in a timely manner and suitability staff were not maintaining the required official personnel records. These irregularities occurred because the Office of Operations, Security, and Preparedness (OSP) did not monitor compliance with program requirements. Furthermore, OSP and the Veterans Health Administration (VHA) did not effectively manage human capital or ensure that sufficient and appropriate staff were assigned suitability functions. The OIG also found VA could not independently attest to the status of suitability determinations. HR Smart investigation data were not reliable for reporting on the status of suitability determinations. The data fields necessary to track investigations to conclusion were missing or incomplete. The OIG had to rely on the Office of Personnel Management’s data to analyze VHA’s suitability actions and to determine the status of investigations. This occurred because OSP and VHA did not effectively manage their processes so sufficient data were created and maintained in support of the program’s objectives. The OIG recommended OSP establish robust oversight, implement and report on the monitoring program, ensure reliable data are collected and maintained, establish quality and performance metrics, and obtain VHA’s corrective action plans. The OIG also recommended VHA ensure investigations are initiated and adjudicated, and implement requirements to improve governance. The OIG recommended OSP coordinate with VHA to correct current data integrity issues and improve data accuracy, implement a plan to review the suitability status of all VHA personnel and to correct delinquencies, and evaluate human capital needs to manage workload.

This is a publication by GAO's Office of Inspector General (OIG) that concerns internal GAO operations. This report addresses (1) the extent to which agency need, as directed by management or self-identified by a criminal investigator, required GAO’s criminal investigators to work hours beyond their regularly scheduled 40-hour workweek; and (2) whether criminal investigators met the Law Enforcement Availability Pay (LEAP) Act substantial hours eligibility requirement for receiving LEAP premium pay.