Federal Reports

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 VA Maryland Health Care System, which includes the Baltimore, Loch Raven, and Perry Point VA Medical Centers, and multiple outpatient clinics in Maryland. The inspection covered key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.At the time of the OIG’s virtual inspection, the healthcare system’s leadership team had worked together for nearly three months, except for the interim Deputy Director, who was assigned one day prior to the inspection. Selected employee survey responses demonstrated satisfaction with leadership and maintenance of an environment where staff felt respected, and discrimination was not tolerated. Patient experience survey data implied general satisfaction with the outpatient care provided, however, leaders had opportunities to improve inpatient care satisfaction. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. The executive leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and factors contributing to poorly performing quality and efficiency measures.The OIG issued eight recommendations for improvement in three areas:(1) Quality, Safety, and Value• Peer review processes(2) Care Coordination• Patient transfer monitoring and evaluation• Inter-facility transfer form completion• Medication list transmission• Nurse-to-nurse communication(3) High-Risk Processes• Staff training

The VA Office of Inspector General (OIG) conducted this review to assess the oversight and stewardship of funds by the VA El Paso Healthcare System and to identify potential cost efficiencies in carrying out medical center functions. The review assessed the following financial activities and administrative processes to determine whether the healthcare system had appropriate oversight and controls in place: open obligations oversight, purchase card use, Medical/Surgical Prime Vendor-Next Generation (MSPV-NG) program use, and pharmacy operations.The team identified several opportunities for improvement:• The healthcare system did not perform required reviews for five of 10 inactive open obligations, totaling almost $3 million, risking funds not being used in the year they were appropriated, as required.• The healthcare system did not always properly oversee purchase card transactions. Twenty-two of 38 sampled transactions contained errors that resulted in $159,000 in questioned costs. This occurred because cardholders did not adhere to VA policy on document retention.• The healthcare system did not meet the goal to purchase 90 percent of formulary items from the MSPV-NG prime vendor, reaching only 14 percent on average. For 21 of 30 sampled purchase records, the review team questioned about $26,500 because the healthcare system did not submit national contract waiver requests, as required by VA policy.• The healthcare system could improve pharmacy efficiency by narrowing the gap between observed drug costs and expected drug costs, bringing the turnover rates closer to the VHA recommended level, and meeting requirements for noncontrolled drug line audits.The OIG made 12 recommendations to the VA El Paso Healthcare System director to use as a road map to improve financial operations. The recommendations address issues that, if left unattended, may eventually interfere with effective financial efficiency practices and the strong stewardship of VA resources.

This Insights Report highlights identity fraud related challenges in federal programs during the COVID-19 pandemic. By evaluating previous oversight work in this space from members of the PRAC’s Identity Fraud Reduction and Redress Working Group, this report presents best practices to reduce identity fraud before it occurs and to assist victims of identity fraud if it does occur. These best practices may be helpful for federal agencies to utilize moving forward. This report also identifies that across the federal government there is a larger focus on reducing identity fraud up front, while helping and supporting identity fraud victims has not been a concentrated focus area across the federal government. As such, the PRAC’s Identity Fraud Reduction and Redress Working Group will increase its focus on victim redress processes and claimant satisfaction.

The Federal Election Commission (FEC) Office of the Inspector General (OIG) initiated an inquiry on March 10, 2022, based on a referral from the Office of the Chief Information Officer (OCIO) that an agency employee with the Office of General Counsel (OGC) had lost her FEC laptop and may have failed to promptly report the loss in accordance with FEC policy.

We found that an energy company exceeded venting and flaring limits and that BSEE’s annual inspections are insufficient to identify similar issues.