Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the Washington DC VA Medical Center. The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic 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 (CLABSI). The OIG also followed up on the Facility’s progress with action plans established for a recent hotline report. The OIG noted frequent changes with Facility leaders and organizational risks with the lack of evidence of ongoing, coordinated efforts to improve identified deficiencies, employee relations, and patient care. Facility leaders, who were aware of SAIL data, employee/patient survey results, and patient safety indicators, need to take actions that improve care and performance of the Quality of Care and Efficiency metrics that are likely contributing to the current “1-Star” rating. The OIG noted findings in six processes reviewed and had an incidental finding that significantly impacts quality care. The OIG issued 18 recommendations attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. These are: (1) QSV • Peer review and root cause analysis (RCA) action implementation • Inpatient admissions and continued stay reviews • Interdisciplinary review of utilization management data • RCA results feedback (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations (3) EOC • Construction site infection prevention • Sterile supplies • Environmental cleanliness • Medical equipment inventory and safety inspections • Mental Health seclusion room safety (4) CS Inspection Program • Physical security • CS inventory balance adjustment process • CS Coordinator position description • Reconciliation of CS returns to pharmacy (5) Geriatric Evaluations • Program oversight and evaluation (6) CLABSI • Staff education (7) Timely scanning of patient reports

Transmittal to OMB

As part of our annual audit plan, we performed an audit of costs billed to the Tennessee Valley Authority (TVA) by GE Mobile Water, Inc. (GE) for providing water processing services, chemicals, and other related products and services under Contract No. 75130. Our audit included approximately $40.898 million in costs billed to TVA from January 1, 2014, to <br> April 30, 2018. Our audit objective was to determine if GE billed TVA in accordance with the contract terms.In summary, we determined GE generally billed TVA in accordance with the contract terms. However, we found (1) GE did not maintain adequate documentation of the index it used to calculate the fees billed to TVA and (2) the contract terms regarding document retention could be strengthened.(Summary Only)

The VA Office of Inspector General (OIG) conducted a healthcare inspection at a Veterans Integrated Service Network 21 medical facility in response to a complaint alleging that a provider’s deficient practices placed patients at risk for poor outcomes, the provider mismanaged clinic time and associated resources, and system leaders had not been fully responsive to these concerns. The provider did not order stat venous ultrasounds on three patients with suspected deep vein thrombosis (DVT). However, this failure did not violate clinical or professional guidelines. Still, the provider did not document clinical assessment of pretest probability of patient risk for DVT, as recommended by guidelines to direct additional testing and treatment. Two of the three patients subsequently tested positive for DVT. Supplies were removed from the system’s secure storage device used for medical supplies without proper accounting of the items. However, the failure could not be attributed to a specific user or users. The OIG substantiated that the provider completed a telephone consult rather than seeing the patient, but the team found this to be reasonable under the circumstances. The OIG was unable to determine whether the provider consistently adhered to good infection control practices, used high-cost items unnecessarily, arrived late and left early from clinic, or improperly accepted a gift. The OIG did not substantiate that the provider “padded” clinics, did not follow the diabetic foot ulcer algorithm, and failed to evaluate a patient prior to his cardiopulmonary arrest. Further, the OIG did not substantiate that system leaders failed to hold the provider accountable for alleged quality deficits or improper actions. System leaders conducted reviews and took appropriate actions as needed. One recommendation was made to evaluate the care of the two patients with suspected DVT to determine whether opportunities for more timely diagnosis of DVT existed.