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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
U.S. Agency for International Development
Financial Audit of Deloitte Yousuf Adil's Management of the Sindh Capacity Development Project in Pakistan, Contract AID-391-C-15-00010, June 1, 2016, to May 31, 2018
Closeout Audit of the Fund Accountability Statement of America-Mideast Educational and Training Services, Inc., Palestinian Faculty Development Program in West Bank and Gaza, Cooperative Agreement 294-A-00-05-00234-00, July 1, 2014, to June 30, 2015
Closeout Audit of Palestine Trade Center, Creating a Competitive Edge of the Palestinian MSMEs in the Local and Potential Export Markets Project in West Bank and Gaza, Cooperative Agreement AID-294-A-17-00011, September 25, 2017 to January 31, 2019
Closeout Examination of APCO/ArCon Construction and Services LLC Compliance With Terms and Conditions of Task Order 294-TO-16-00001, Hebron Northern and Southern Entrance Roads in West Bank and Gaza, June 10, 2016 to July 13, 2017
Investigative Summary: Finding of Misconduct by a Senior Official in the Executive Office for Immigration Review for Engaging in a Prohibited Personnel Practice
This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Southern Oregon Rehabilitation Center and Clinics, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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 leadership team appeared relatively new, having worked together for six weeks, as of the week of the OIG’s visit. Selected survey scores revealed opportunities for the associate director to improve employee satisfaction and provide a safe workplace environment where employees feel comfortable with bringing forth issues or ethical concerns. Opportunities also exist for leaders to improve patient satisfaction. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance of measures contributing to the SAIL “3-star” quality rating. The OIG issued five recommendations for improvement: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation processes (3) Antidepressant Use among the Elderly • Patient/caregiver education and evaluation of understanding • Medication reconciliation (4) Abnormal Cervical Pathology Results Notification and Follow-up • Patient notification of abnormal results
