Federal Reports

OIG completed a healthcare inspection of Management of Disruptive and Violent Behavior in Veterans Health Administration (VHA) facilities. The purpose of the evaluation was to determine whether facilities complied with selected VHA requirements. OIG conducted this review at 29 VHA medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2016 through March 31, 2017. OIG noted high compliance in multiple areas, including that all facilities had implemented policies addressing prevention and management of disruptive/violent behavior and had conducted annual Workplace Behavioral Risk Assessments. However, Facility Directors needed to address employee-generated violence by establishing required Employee Threat Assessment Teams. Additionally, while facilities had established Disruptive Behavior Committees/Boards, Facility Directors need to ensure attendance at meetings by all required members. Patient Record Flags (PRF) in patients’ electronic health records communicate to clinicians that certain patients have exhibited disruptive/violent behavior. While most clinicians appropriately documented new flags, OIG found noncompliance with a requirement to inform patients about the PRFs and about the right to request to amend or appeal placement of the PRFs. OIG stressed the importance of informing patients for whom Orders of Behavioral Restriction (a type of therapeutic limit setting sometimes required to manage care for patients whose behavior is disruptive) were issued. Facilities had implemented training plans that used the official Prevention and Management of Disruptive Behavior training curriculum. However, facilities need to improve in providing newly hired employees with Level I Prevention and Management of Disruptive Behavior training and additional levels as indicated by the risk of the area assigned. VHA guidance focuses on managing patients who exhibit disruptive/violent behavior; ensuring a safe workplace would benefit from guidance concerning disruptive/violent behavior that involve non-patients as victims or perpetrators. We made four recommendations.

On January 30, 2018, an Amtrak supervisor was dismissed after an administrative hearing found that he violated company policy by accepting gifts and gratuities from Bayway Lumber (Bayway), a former Amtrak-approved vendor based in Linden, New Jersey.

We determined that DHS’ Suspension and Debarment Instruction is outdated and is missing needed definitions, as well as detailed requirements and procedures for documenting decisions on administrative agreements, which mandate improvements rather than suspending or debarring companies and organizations. The Department did not adequately document five of seven administrative agreements approved between fiscal year 2012 and February 2017. The Department does not have a centralized system to track suspension and debarment activities, which may have contributed to DHS’ inaccurate FY 2016 reporting of suspensions and debarments. We also determined that for an 8-month period, Federal Emergency Management Agency suspension and debarment staff did not promptly update government-wide systems to reflect debarments and administrative agreements, but they have since uploaded this information. Department-level staffing issues may be hindering efficient and effective handling of suspensions and debarments. We recommended that the Department update the DHS Suspension and Debarment Instruction, implement a centralized department-wide tracking system, enact performance measures in employee performance plans, and examine staffing levels. We made four recommendations to DHS to strengthen its Suspension and Debarment Program and improve oversight and accountability. DHS concurred with our four recommendations and took or planned to take corrective action to improve oversight and accountability in its Suspension and Debarment Program.