Federal Reports

The VA Office of the Inspector General (OIG) conducted this audit to follow up on previous reviews of its capital asset programs, which have identified areas of improvement for both major and minor construction projects, and to determine whether VA effectively managed the procurement and awarding of major medical leases under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA). The OIG found that VA major medical leases authorized by VACAA are approximately 22 months behind schedule on average. The management structure of the lease acquisition process spans multiple lines of authority and requires many decisions to execute a lease contract. As a result, lease acquisitions are often slowed when project managers are confronted with conflicting opinions from different management groups. VA has taken some steps to improve the major lease acquisition process, including simplifying the solicitation documentation to better align with General Services Administration practices and changing VA’s mission-critical building standards for leases to better align with similar private sector facilities. However, several of the recommendations remain unaddressed. The OIG recommended VA ensure there are adequate funds available to routinely conduct planning activities including developing requests for lease proposals while waiting for congressional authorization; reconsider centralizing major medical lease acquisition funding activities, make certain adequate resources are available to deliver leases on schedule; ensure that the prospectus cost estimates provided to Congress are accurate; establish clear lines of authority for critical lease acquisition decisions; and adhere to appropriate security measure requirements by performing Interagency Security Committee risk evaluations prior to solicitation. Implementing these recommendations should result in faster and more cost-efficient acquisition of major medical leases.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations related to the discharge of a patient from an inpatient mental health unit at a Veterans Integrated Service Network 4 Medical Facility. The patient was arrested by VA Police, discharged to a federal detention center (FDC), and died eight days later. The OIG identified concerns related to discharge planning processes, voluntary and involuntary admission, use of guidance regarding the patient’s legal and psychiatric status, and patient record flag management. The OIG did not substantiate that the patient died by suicide in the FDC. The Associate Medical Examiner identified the cause of death as hypertensive and atherosclerotic cardiovascular disease and the manner of death as natural. The OIG substantiated that facility staff failed to engage in proper treatment and discharge planning processes. Specifically, staff failed to: • Include the patient and family in treatment and discharge planning, • Address the patient’s decision-making capacity, • Identify and consistently document the patient’s surrogate, • Provide clinical hand-off communication to the receiving mental health providers, despite the patient’s medical and psychiatric acuity and complex medication regimen, • Assign a mental health treatment coordinator, • Obtain a release of information for the VA Police to obtain discharge information, • Obtain consent for voluntary admissions from the surrogate for patients who lack decision-making capacity, and • Consider accessing expert consultative resources to prepare more effectively for patient treatment and discharge. The OIG made 10 recommendations related to inclusion of family in inpatient mental health treatment and discharge planning; assessment of decision-making capacity and voluntary admission status; documentation of a patient’s surrogate; provision of a complete diagnostic summary to receiving providers; assignment of a mental health treatment coordinator; release of information processes; inpatient mental health unit voluntary and involuntary admission processes; and access to consultative resources.

During the week of June 10, 2019, we visited five Border Patrol stations and two ports of entry in the Rio Grande Valley sector and observed serious overcrowding and prolonged detention of children and adults that require immediate attention. Specifically, Border Patrol facilities in the Rio Grande Valley do not have the capacity to hold the thousands currently in custody, and have been holding hundreds of children in custody beyond the 72 hours generally permitted under the TEDS standards and the Flores Agreement.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the James H. Quillen VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. At the time of the review, 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; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared stable, with three of the four positions permanently filled for over one year prior to the OIG’s on-site visit. Selected survey scores related to employees’ satisfaction and trust in the facility’s executive leaders were better than VHA averages. Patient experience survey data revealed that scores related to satisfaction with the facility were above VHA averages. The OIG’s 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 sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “2-star” quality ratings. The OIG issued five recommendations for improvement in the following areas: (1) Medication Management: Controlled Substances Inspections • Completion of inspections on day initiated • Reconciliation of dispensing and return of stock for one random day • Emergency drug cache inspections (2) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education on medications

DHS components did not always properly solicit, award, and manage contracts according to Federal and departmental regulations. In fiscal year 2016, DHS awarded $2.4 billion in contract actions that were valued at less than $300 million per action. For this audit, we reviewed $153.2 million of the $2.4 billion in contract actions that DHS awarded. We found that components did not document their oversight in the procurement files for 18 — about 62 percent — of the 29 contract files reviewed. This represented about $112.1 million of the $153.2 million contract actions awarded in fiscal year 2016. This occurred because components lacked a comprehensive contract management process for maintaining contract files, and reviews conducted by procurement personnel did not ensure that contract personnel performed the required procurement processes. As a result of these deficiencies, two contract files valued at $4.9 million could not be located. In one instance, DHS was unable to address contractor performance issues to recover about $1 million. Also of note, six procurement documents from four contracts valued at $9.4 million did not have authorized signatures, one contracting officer exceeded the warrant authority by $12,500, and two firm-fixed-price contracts totaling $2.3 million were not finalized. Furthermore, components lost procurement documents, mismanaged contracts, and did not adhere to contract policy requirements. These problems resulted in misspent funds and impaired the government’s ability to take action when contractors do not comply with the terms of the procurement.

OIG data analytics identified the Concord MPO recorded local travel reimbursement in Account Identifier Code (AIC) 538, Local Travel Transportation, totaling $26,834, or 79 percent of all local travel reimbursements in the Bay Valley District for the period April 1, 2018, through February 28, 2019. Local travel reimbursements at the Concord MPO were $9,805 at the end of the first quarter of fiscal year (FY) 2019 and $12,346 for two months of activity of Quarter (Q) 2, FY 2019, significantly higher than the prior quarters. The objective was to determine whether local travel reimbursements at the Concord MPO were appropriate and properly supported.

During a prior review, we determined that New York claimed Medicaid reimbursement for home and community-based services (HCBS) under a Medicaid waiver program that did not comply with Federal requirements.New York's Nursing Home Transition and Diversion (NHTD) is an HCBS waiver program. Our objective was to determine whether New York claimed Medicaid reimbursement for NHTD waiver program services in accordance with certain Federal and State requirements.