Federal Reports

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 1: VA New England Healthcare System, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following VISN 1 facilities were also performed: VA Central Western Massachusetts Healthcare System, Leeds, MA; Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; and Manchester VA Medical Center, NH. The VISN 1 leadership team appeared relatively stable. Employee satisfaction scores were generally better than VHA averages. However, opportunities appear to exist for the network director to improve employee satisfaction; the deputy network director to model servant leadership; and the network director, deputy network director, and chief medical officer to reduce employee moral distress at work. Patient experience results were above VHA averages. VISN 1 leaders supported efforts to provide accessible and inclusive care for women veterans, and access metrics and clinician vacancies did not identify any significant organizational risks. Leaders appeared knowledgeable about efforts taken to reduce veteran suicide as well as selected Strategic Analytics for Improvement and Learning and community living center performance metrics; but should continue to support facility actions to improve care provided throughout VISN 1. The OIG issued 12 recommendations for improvement: (1) Quality, Safety, and Value • Acute inpatient stay reviews • Utilization management data reviews • Minimum of eight root cause analyses (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • VISN comprehensive environment of care program • VISN emergency management committee processes (4) Medication Management: Controlled Substances Inspections • Quarterly trend report reviews

What We Looked AtWe queried and downloaded 84 single audit reports prepared by non-Federal auditors and submitted to the Federal Audit Clearinghouse between September 1, 2019 and December 31, 2019, to identify significant findings related to programs directly funded by the Department of Transportation (DOT). What We FoundWe found that reports contained a range of findings that affected DOT programs. The auditors reported significant noncompliance with Federal guidelines related to 19 grantees that require prompt action from DOT’s Operating Administrations (OA). The auditors also identified questioned costs totaling $1,135,453 for six grantees. RecommendationsWe recommend that DOT coordinate with the impacted OAs to develop a corrective action plan to resolve and close the findings identified in this report. We also recommend that DOT determine the allowability of the questioned transactions and recover $1,135,453, if applicable.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Alaska VA Healthcare System,covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; and Women’s Health:Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s executive leaders had been working together since August 2017. Employee satisfaction scores were generally higher than VHA averages. Leaders seemed actively engaged with patients and appeared to support efforts to improve and maintain patient safety and quality care. Review of accreditation findings, sentinel events, and patient safety indicator data did not identify any substantial organizational risk factors. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning metrics but should continue to act to improve performance of measures contributing to the Strategic Analytics for Improvement and Learning “3-star”quality rating. The OIG issued six recommendations for improvement: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medication Management: Controlled Substances Inspections • Override report review (3) Mental Health: Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver medication education • Medication reconciliation (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership

Letter to The Honorable Russell T. Vought, Acting Director, Office of Management and Budget

Letter to The Honorable Russell T. Vought, Acting Director, Office of Management and Budget

OIG issues this advisory letter to alert Lifeline carriers, consumers and the public to the potential for widespread carrier non-compliance with the Lifeline usage rule.