Federal Reports

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to review quality of care and patient safety concerns identified by an OIG medical consultant after providing assistance during an OIG Office of Investigations inquiry into an unexpected patient death at the facility. The OIG determined that quality of care deficiencies may have contributed to a patient’s death during the Unit 7E admission. Unit 7E providers did not monitor the patient for electrocardiogram changes or drug-drug interactions. Staff and providers documented signs consistent with oversedation, but did not intervene, communicate directly with each other, or add team members on as additional signers to the electronic health record. The facility did not comply with Veterans Health Administration requirements for issue briefs, root cause analyses, and peer reviews. Unit 7E staff did not follow the facility’s observation policy. Facility providers did not adhere to policies requiring discussion, documentation, and a patient signed informed consents prior to initiating methadone treatment. Leaders implemented measures to address deficiencies including equipment issues identified by the rapid response team and training needs to mitigate the potential for future patient safety events. The OIG made nine recommendations related to monitoring patient care and communication; compliance with review requirements, observation policy, and signed consent; and monitoring of findings and action plans.

Due to the risk of incorrectly dispositioning nuclear outage materials, we initiated an evaluation of nuclear outage material management. Our objective was to determine if TVA is managing designated outage material following an outage to maximize use and minimize cost. We determined TVA generally managed designated outage materials to maximize use and minimize cost. Specifically, we found (1) no instances where TVA missed material redeployment opportunities for designated outage materials and (2) all outage items designated for surplus and subsequently repurchased were warranted. However, we identified opportunities for improvement related to documentation for material returns and a TVA inventory database control.

The Office of the Inspector General conducted a review of Shawnee Fossil Plant (SHF) to identify operational and cultural strengths and areas for improvement that could impact SHF’s organizational effectiveness. Our report identified strengths that positively affected the day-to-day activities of SHF personnel. These strengths related to (1) organizational alignment, (2) teamwork within working groups and with other SHF departments, (3) effective leadership, (4) positive ethical culture, and (5) resources necessary for job execution. However, we also identified a risk related to inadequate asset maintenance activities that could impact SHF’s effectiveness and its continued ability to meet its responsibilities in support of Power Operations’ mission.

The Peace Corps works in countries with histories of civil wars, ethnic clashes, cross-border conflicts, rebel incursions, foreign occupations, genocide, violent protests, and repressive dictatorships. These conflicts often have on-going impacts. This review evaluated the adequacy of Peace Corps guidance on new country entries and re-entries in conflict-affected environments.We found that the Peace Corps needed to more fully assess the conflict status of countries under consideration for opening, re-opening, or expanding a Peace Corps program. The agency should also address gaps in the current “New Country Assessment Guide” and the “New Country Entry Guide” to improve the efficiency and effectiveness of the agency’s processes and procedures for opening posts in conflict-affected environments.