Federal Reports

The Office of the Inspector General conducted a review of the Hydro Generation, North Eastern Region (Hydro NE) to identify operational and cultural strengths and risks that could impact Hydro NE’s organizational effectiveness. Our report identified strengths within Hydro NE related to (1) organizational alignment, (2) positive interactions within and outside of Hydro NE, (3) first-line leadership, and (4) positive ethical culture. However, we also identified risks that could impact Hydro NE’s ability to meet its responsibilities in support of Power Operations’ mission. These included risks related to perceptions of (1) inadequate staffing and (2) lack of accountability.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Central California VA Health Care System (the facility), which covers leadership, organizational risks, and key processes associated with promoting quality care. Focus 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. At the time of the OIG’s on-site visit, the facility’s executive leadership team appeared relatively stable with three positions permanently filled for over two years and one position vacant for approximately one month. For selected employee survey scores, the OIG noted that employees appeared generally satisfied. However, opportunities appeared to exist to improve inpatient and Patient-Centered Medical Home outpatient experiences. Review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to improve performance of measures contributing to the SAIL “2-star” and CLC “3-star” quality ratings. The OIG issued 11 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • Medication safety • Mental health unit panic alarm testing response time documentation (4) Controlled Substances Inspections • Inventory balance adjustment processes (5) Military Sexual Trauma (MST) Follow-up and Staff Training • Providers’ training (6) Emergency Departments and Urgent Care Center Operations • Backup call schedule

The VA Office of Inspector General (OIG) conducted a healthcare inspection, in response to a notification that a hospitalized patient died by suicide and a subsequent request from House Veterans Affairs Committee Chairman Mark Takano, to review the circumstances of the death. Inpatient death by suicide is an event that is largely preventable. The OIG determined the patient received reasonable care during the admission. The patient was appropriately screened for suicide risk, provided medication management, placed on close observation status, and had on-going assessments, interventions, and a discharge plan. However, the facility failed to abate identified safety hazards on the unit. Patient safety cameras were nonoperational and 15 minute patient safety rounds policy lacked clear guidance and expectations for staff. The facility did not meet Veterans Health Administration (VHA) requirements for staffing an Interdisciplinary Safety Inspection Team or training staff regarding the Mental Health Environment of Care Checklist (MHEOCC). The OIG found a lack of oversight by both the VHA MHEOCC Work Group and Veterans Integrated Service Network (VISN) 8. The OIG also found facility leaders lacked awareness and failed to educate themselves on patient safety requirements regarding the mental health unit. While the OIG team determined the facility responded promptly to the adverse patient event and was in the process of implementing improvement actions, facility leaders and managers only started to respond aggressively to long-standing deficient conditions after a sentinel event occurred. The OIG made one recommendation to the Under Secretary for Health, one recommendation to the VISN Director, and nine recommendations to the Facility Director related to leaders’ responsibilities regarding mental health, environment of care, and patient safety; MHEOCC training; risk mitigation; facility policy regarding patient safety and law enforcement cameras on the locked mental health unit; 15-minute safety rounding policy; and staff training.

The Office of the Inspector General (OIG) contracted with ATC Group Services LLC (ATC), to conduct a review of groundwater monitoring activities at the Kingston Fossil Plant Peninsula Disposal Unit to determine the quality of the program and adherence to regulatory standards. ATC stated that in their opinion, monitoring activities performed at TVA Kingston Fossil Plant Peninsula Disposal Unit are in adherence with guidelines for the Environmental Protection Agency and the Tennessee Department of Environment and Conservation. Furthermore, ATC stated the work performed appears to be of high quality and does not likely result in any discrepancies for the program.

Our objective was to assess the Postal Service’s employee background screening process to determine whether individuals selected for employment are suitable to maintain the safety and security of the mail and uphold public trust in the Postal Service.

Our objective was to evaluate the HVAC PM process at mail processing facilities. We reviewed a statistical sample of 118 facilities to assess HVAC PM performance for a two-year period from September 1, 2016, through October 31, 2018.

Our audit objective was to determine whether the U.S. Patent and Trademark Office monetary awards were (a) granted in compliance with the relevant award criteria and (b) sufficiently documented. Our audit scope included awards related to patent examiners’ performance and productivity ratings in fiscal year 2016.