Federal Reports

The VA Office of Inspector General (OIG) conducted a rapid response healthcare inspection at the Charlie Norwood VA Medical Center in Augusta, Georgia, to assess allegations from an anonymous complainant that deficiencies in care coordination between facility staff and remote telemedicine intensive care unit (tele-ICU) staff resulted in deaths, injuries, or poor outcomes for patients in the critical care unit (CCU) after general surgery residents were withdrawn. The names of six patients were included in the complaint. The OIG substantiated that deficiencies in care coordination existed between facility staff and tele-ICU staff after the residents were withdrawn but was unable to determine that the withdrawal resulted in deaths, injuries, or poor outcomes for patients identified in the complaint. The OIG found that facility leaders were aware of the potential withdrawal of the residents but did not take actions to ensure that effective processes were in place and failed to be proactive in developing, disseminating, and ensuring effectiveness of relevant algorithms.The OIG also found a combination of a misunderstanding of the tele-ICU program and a lack of facility staff engagement with tele-ICU staff to assist with co-management of monitored patients contributed to challenging and impaired communication processes. The tele-ICU was not integrated into facility quality management processes and facility staff and tele-ICU staff did not report, and therefore patient safety staff did not evaluate, tele-ICU patient safety events.Six recommendations were made to the Facility Director related to communication and coordination, on-call processes, medicine and surgery staff responsibilities, patient safety reporting training, quality review collaboration processes, and orientation and competency training. Two recommendations were made to the Veterans Integrated Service Network 10 Tele-ICU Medical Director related to patient safety reporting training and coordination of patient care reviews.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Charlie Norwood VA Medical Center and multiple outpatient clinics in Georgia and South Carolina. 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 worked together for seven months at the time of the OIG’s visit. Survey results revealed opportunities for the Director to improve employee satisfaction. Survey data also indicated that patients were somewhat satisfied with their care. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial risk factors. However, the OIG identified significant concerns with equipment purchased and corresponding lack of full implementation. Executive leaders were able to speak knowledgeably about actions taken during the previous 12 months to maintain or improve performance. Leaders were also knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models.The OIG issued 20 recommendations for improvement in five areas:(1) Quality, Safety, and Value• Committee processes• Peer review• Root cause analyses(2) Medical Staff Privileging• Exit review process(3) Environment of Care• Environmental safety and cleanliness• Information protection(4) Women’s Health• Gynecological care coverage• Women’s health providers and clinical liaison(5) High-Risk Processes• Standard operating procedures• Risk analysis• Equipment storage• Staff training

The Katy Carrier Annex is in the Houston District of the Southern Area. The unit has 48 city routes, 32 rural routes, and seven contract routes delivered by 62 city carriers, 49 rural carriers, and seven contract carriers. We chose the Katy Carrier Annex based on the number of stop-the-clock (STC) scans occurring at the delivery unit. Our objective was to evaluate select mail delivery and customer service operations at the Katy Carrier Annex.

Our objective for this report was to complete our review of the company’s use of Coronavirus Aid, Relief, and Economic Security (CARES) Act funds and its controls to accurately track and report on them.We found that the company is effectively using, accounting for, and reporting on the $1.018 billion it received through the CARES Act, and that it has addressed the initial risks we identified in our interim report published in August 2020. If Congress approves additional assistance, we identified two opportunities for the company to adjust its controls for approving paid leave for coronavirus-related absences and applying the CARES Act formula for calculating state bills for services provided under section 209 of the Passenger Rail Investment and Improvement Act of 2008. These adjustments would make the controls more consistently effective.

We determined if FS had the proper authority and followed Federal laws and regulations when awarding a $2 million grant to the State of Alaska.

An Amtrak Police Department employee resigned on December 15, 2020, in lieu of a disciplinary hearing for violating various company policies. Our investigation found that the employee engaged in outside employment during his shifts and while on sick leave. In doing so, the employee also violated his union agreement. The employee shopped online and left for long periods of time to purchase supplies for his outside employment during his APD shifts and engaged in his outside employment while the company was paying him to attend mandatory training. During the training, he took significant steps to hide these actions from being discovered.

The OIG investigated allegations that Extraction Oil and Gas (EXT) drilled multiple horizontal wellbores through a railroad right-of-way (ROW) in Weld County, CO, containing Federal minerals without first obtaining a Federal lease or drilling permit.We found that three companies (EXT, Mineral Resources, Inc., and PDC Energy, Inc.) illegally drilled oil wells through a railroad ROW and produced unleased Federal minerals. Based on our investigation, the U.S. Attorney’s Office for the District of Colorado entered into civil settlement agreements with all three companies to resolve the violations and recover public revenues. The settlements totaled more than $1,787,000.