Federal Reports

Pursuant to an Office of the Inspector General subpoena, we obtained Alaska Department of Health data that contained the personally identifiable information (PII) of 217,851 individuals the State recorded as deceased from January 13, 1900 to February 14, 2023. We processed thedata through the Social Security Administration’s (SSA) Enumeration Verification System and against SSA payment records and identified 119 beneficiaries in current or suspended payment status whose PII matched that of deceased individuals in the Alaska death data.

EAC OIG, through the independent public accounting firm of Brown & Company CPAs and Management Consultants, PLLC, audited EAC’s information security program for fiscal year 2023 in support of the Federal Information Security Modernization Act of 2014 (FISMA). The objective was to determine whether EAC implemented selected security controls for certain information systems in support of FISMA.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the VA Palo Alto Health Care System, which includes medical centers in Palo Alto, Menlo Park, and Livermore and multiple outpatient clinics in California. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (focusing on emergency department and urgent care center suicide prevention initiatives)The OIG issued four recommendations for improvement in two areas:1. Leadership and Organizational Risks• Institutional disclosures for sentinel events2. Environment of Care• Preventive maintenance on medical equipment• Access to medications only by authorized staff• Clean and safe environment

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Charlie Norwood VA Medical Center (facility) in Augusta, Georgia, to assess allegations that a spinal cord injury (SCI) patient was inappropriately admitted to an inpatient SCI unit following surgical treatment of femur and tibia bone fractures.Allegations included that the patient was not consistently monitored for blood pressure or laboratory results, had significant postoperative bleeding requiring transfer to the critical care unit (CCU), and had multiple blood transfusions. The OIG identified a concern related to a lack of communication between an orthopedic surgeon and the SCI interdisciplinary team.The OIG did not substantiate that the patient’s postoperative admission to the SCI unit was inappropriate. Postoperative SCI patients are admitted to the SCI unit unless there are complications during surgery or other concerns. The patient met post-anesthesia care unit discharge criteria, and several facility SCI staff were familiar with the patient’s care.The patient experienced significant postoperative bleeding, which resulted in the patient’s transfer to a higher level of care and multiple blood transfusions. However, the OIG determined this event was not a result of the patient’s admission to, or the postoperative care provided on, the SCI unit. SCI nurses’ close monitoring of the patient and timely initiation of a rapid response contributed to the patient’s successful recovery.The OIG identified a lack of communication between the surgeon and SCI staff related to the outpatient management of the patient’s leg fractures prior to surgery. Establishing a process to ensure improved communication and coordination between the Surgery Service and the SCI Service may benefit SCI patients with surgical needs.The OIG made one recommendation to the Facility Director related to establishing a process to optimize communication.