Federal Reports

This is a publication by GAO's Office of Inspector General (OIG) that concerns internal GAO operations. The OIG contracted with the independent certified public accounting firm of Williams Adley to audit GAO’s compliance with the Digital Accountability and Transparency Act of 2014 (DATA Act), and produce this report. This report addresses (1) the completeness, accuracy, timeliness, and quality of the financial and award data GAO submitted for publication on USASpending.gov for the first quarter of fiscal year (FY) 2019 and (2) GAO’s implementation and use of the Government-wide financial data standards established by the Office of Management and Budget (OMB) and the Department of the Treasury.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care at the Hunter Holmes McGuire VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility had generally stable executive leadership, but the OIG had concerns with long-term Nursing Service leadership vacancies and minimal recruitment efforts. Employee satisfaction and patient experiences in the inpatient and specialty care settings also need improvement. The leadership team should review steps to identify cases that may need institutional disclosures and evaluate the process of identifying improvement opportunities. The leadership team needs to improve their knowledge about selected SAIL and CLC metrics and the actions necessary to sustain and improve performance that contribute to the SAIL “4-star” and CLC “1-star” quality ratings. The OIG issued 21 recommendations: (1) Quality, Safety, and Value • Physician utilization management advisors’ documentation • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • General cleanliness and safety (4) Controlled Substances Inspections • Controlled substances inventories/checks, documentation, and reconciliation • Pharmacy inspections and medication destruction • Verification of prescription pads and written prescriptions (5) Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (6) Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications • Medication reconciliation (7) Abnormal Cervical Pathology Results Notification and Follow-up • Full-time women veterans program manager (8) Emergency Departments and Urgent Care Center Operations • Licensed mental health provider availability • Directional signage

The VA Office of Inspector General (OIG) conducted a rapid response inspection to evaluate allegations that some patients, presenting with mental health-related issues to the Louis Stokes Cleveland VA Medical Center Emergency Department, were not adequately assessed prior to transfer to the facility’s Psychiatric Observation and Assessment Center (PAOC), thus placing patients with medical conditions at risk. The OIG substantiated the allegation; however, the conditions described in the allegation generally occurred prior to August 2018 and facility policy then did not require patients with primarily mental health concerns to be screened in the Medical Emergency Department first. Following visits from The Joint Commission and the Office of Medical Inspector in July 2018, the facility changed its policy to require that all patients presenting with intoxication or an acute mental health condition are medically screened in the Emergency Department before transfer to the PAOC. To determine if the facility was following the new policy, the OIG reviewed 205 encounters for patients seen in the Emergency Department and subsequently transferred to the PAOC between January 1 and March 31, 2019. The OIG did not substantiate that patients were transferred to the PAOC without medical screening examination notes, were transferred in acute alcohol withdrawal, or were transferred with critical laboratory values. The OIG found no evidence of adverse clinical outcomes related to the management of patients receiving care in the PAOC. In March 2019, the facility issued a policy that defined the procedures for evaluation and treatment of patients presenting with suspected substance intoxication and provided mandatory Clinical Institute Withdrawal Assessment training for all Emergency Department and PAOC staff. The OIG made one recommendation related to the clinical elements to be included in a medical screening examination to deem a patient medically stable prior to transfer to the PAOC.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Tuscaloosa VA Medical Center, 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 executive leadership team appeared relatively stable; and, upon review of the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risk. However, the OIG had concerns regarding the root cause analysis process—corrective actions were not implemented or, if implemented, not measured, allowing existing system vulnerabilities that were not eliminated or controlled and exposing veterans to potential and preventable adverse events. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to take actions to improve performance contributing to the SAIL “3-star” and CLC “2-star” quality ratings. The OIG issued 14 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • General safety and cleanliness • Mental health unit panic alarm testing response times • Comprehensive emergency management plan annual review (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Assignment of a women’s health medical director • Women Veterans Health Committee core membership • Patient notification of abnormal results

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care at the North Florida/South Georgia Veterans Health System, covering leadership, organizational risks, and key processes associated with promoting quality care. Areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations. The facility’s leadership appeared stable, with four of six positions permanently filled for over one year. Employee satisfaction and patient experience survey were similar to or higher than VHA averages. Leaders supported efforts related to safety and quality care; however, patient safety indicator data, along with missing institutional disclosure information and conflicting survey report information, may contribute to organizational risks. The leaders were knowledgeable about SAIL metrics but should continue to improve care and performance of quality of care metrics contributing to current SAIL ratings. The OIG issued 28 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • General cleanliness, maintenance, and biohazardous waste storage • Generator testing (4) Medication Management • Monthly inspections and rotation of inspectors • Verification of orders, drugs held for destruction, prescription pads, hard copy prescriptions, and 72-hour inventories (5) Mental Health • Military Sexual Trauma training (6) Geriatric Care • Patient/caregiver education • Medication reconciliation (7) Women’s Health • Women Veterans Health Committee membership and reporting • Cervical cancer screening data tracking (8) Emergency Departments/Urgent Care Center Operations • On-call social work support • Directional signage (9) Incidental Findings • Medical record scanning backlog • Post Anesthesia Care Unit cardiac monitor inspections and oxygen storage

Our objective was to determine whether the U.S. Postal Service’s Postal Vehicle Service (PVS) Zero Base program was properly implemented and meeting goals. The Postal Service has a PVS fleet and drivers who are career Postal Service employees to move mail between processing facilities, inner-city delivery offices, and local businesses and mailers. PVS is primarily used for distances within a 50-mile radius of their Postal Service location.