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 New Jersey Health Care System in East Orange. The inspection covered key clinical and administrative processes associated with promoting quality care. It 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 inspection, the Director had served in the role since 2017 and some other leaders had been in their positions for over a year. Employee satisfaction survey data revealed opportunities for the Associate Director for Patient Care Services and Associate Director to improve perceptions of leadership and the workplace. Patient experience survey results indicated that males were generally satisfied with their primary care compared to VHA averages. Outpatient survey scores for females were lower than VHA averages. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. Leaders were knowledgeable within their scope of responsibilities about VHA data and factors contributing to poor performance on specific Strategic Analytics for Improvement and Learning measures.The OIG issued eight recommendations for improvement in four areas:(1) Quality, Safety, and Value• Systems redesign and improvement coordinator meeting participation• Peer review processes• Surgical work group meetings(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Patient transfer monitoring and evaluation(4) High-Risk Processes• Disruptive behavior committee meeting attendance

The U.S. Postal Service developed an overarching Continuity of Operations (COOP) plan that allows essential business functions to continue when there is a disruption of normal operations. In support of that plan, the Postal Service developed the Retail Systems COOP (Plan) to provide a methodology for continuing retail operations in the event of a complete Retail Systems Software (RSS) system failure or power or network outage. The Plan ensures that field retail operations provides a limited scope of products and services with minimal customer service impact if retail systems automated functions become unavailable. In fiscal year (FY) 2021 post office retail revenue was over $13 billion.

This management alert presents issues the U.S. Postal Service Office of Inspector General (OIG) identified during the State of Cybersecurity audit (Project Number 21-205). Our objective is to notify Postal Service management of risks associated with security control deficiencies identified during the Assessment & Authorization (A&A) process that have not been mitigated.

This joint audit led by the DoD OIG examined actions taken by the DoD and VA regarding the Cerner Millennium electronic health record (EHR) system being deployed throughout VA and DoD. The audit assessed internal controls and compliance with legal requirements, as well as actions by DoD, VA, and their joint Federal Electronic Health Record Modernization (FEHRM) Program Office to help ensure that health care providers serving veterans can access a patient’s complete EHR. The audit focused on whether those actions would achieve interoperability between DoD, VA, and external health care providers. The joint audit found that DoD and VA took some actions to achieve system interoperability, but there are remaining challenges. DoD and VA did not consistently migrate information from legacy systems into Cerner Millennium to create a single, complete patient EHR; develop interfaces from all medical devices to the system; or ensure users were granted access to Cerner Millennium only for information needed for their duties. A contributing factor for these deficiencies was that the FEHRM Program Office did not develop a clear plan to achieve full interoperability or actively manage the program’s success. The audit report recommends that DoD and VA review FEHRM’s actions and direct the program office to comply with its charter and applicable laws. The FEHRM should also coordinate with DoD and VA on implementing recommendations that include (1) determining the type of health care information that constitutes a complete EHR; (2) implementing a plan for accurately migrating legacy health care information; (3) create medical device interfaces to directly transfer health care information to Cerner Millennium; and (4) implementing a plan to modify system user roles to ensure their access is restricted to only information needed to perform their duties.

The COVID-19 pandemic accelerated efforts by the Veterans Health Administration (VHA) to expand veteran access to telehealth. Accordingly, VHA’s Connected Care Office created a new digital divide consult to issue iPhones to veterans experiencing homelessness who were enrolled in the Department of Housing and Urban Development VA Supportive Housing (HUD-VASH) Program. VHA was already loaning iPads to other veterans who lacked telehealth capable devices through the digital divide consult process. The VA Office of Inspector General (OIG) initiated this review to evaluate whether purchases of iPads and iPhones for veterans met mission needs while minimizing waste during fiscal year (FY) 2020 and through the first two quarters of FY 2021.In July 2020, Connect Care officials purchased 10,000 iPhones with unlimited prepaid data plans for the homeless veterans enrolled in the HUD-VASH program. However, 8,544 of the 10,000 iPhones remained in storage as of July 2021, as demand for the iPhones was much lower than anticipated. The OIG found that this resulted in an estimated $1.8 million in wasted data plan costs. The OIG also identified opportunities for improvement regarding data plans for nearly 81,000 iPads purchased. Because Connected Care did not have strong enough oversight procedures for reducing or eliminating data plan waste, it incurred approximately $571,000 in additional wasted data plan costs.The OIG made two recommendations to the under secretary for health. The first was to establish a realistic goal for days in storage and a process for monitoring days in storage. The second was to determine the viability of initiating data plan charges only when a device is issued to the veteran.