Federal Reports

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Edward Hines Jr. VA Hospital. The inspection covers leadership and organizational risks and key processes associated with promoting quality care. For this inspection, 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 leadership team appeared relatively stable. Employees appeared generally satisfied, but opportunities seemed to exist for employees to feel encouraged to do the right thing. Outpatient satisfaction scores were above VHA averages, while inpatient satisfaction could be improved. The OIG noted organizational risk factors, if uncorrected, can perpetuate noncompliance with requirements and/or lapses in patient safety. The leadership team was generally 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 care and performance of metrics that are likely contributing to the current SAIL “3-star” and CLC “1-star” quality ratings. The OIG issued 10 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Resuscitation episode reviews (2) Medical Staff Privileging • Ongoing professional practice evaluations (3) Environment of Care • Fire safety • Infection prevention (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of education on medications • Medication reconciliation (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Cervical cancer screening data tracking

DHS does not have sufficient policies and procedures to address employee misconduct. Specifically, the Department’s policy does not include procedures for reporting allegations of misconduct, clear and specific supervisor roles and expectations, or clearly defined key discipline terms. These deficiencies occurred because DHS’ Employee Relations office has limited staff, who do not believe they are responsible for managing the allegation process. DHS also does not effectively manage the misconduct program throughout the Department, lacking data monitoring and metrics to gauge program performance. Without oversight through defined policies and program management, DHS cannot make informed decisions to improve the program and ensure all components manage the misconduct process consistently. Additionally, this shortcoming could lead to costly litigation due to inappropriate or unenforceable disciplinary determinations.

We audited the city of Dallas’ management of its community housing development organizations (CHDO). We performed this audit because of our previous audit work on the City’s Home Investment Partnerships program. During that audit, we concluded that the City did not follow HOME regulations and its own policies and procedures in its reconstruction program or the administration of its match contributions, resulting in more than $4.2 million in ineligible funds. Our audit objective was to determine whether the City managed its CHDOs in accordance with U.S. Department of Housing and Urban Development (HUD) regulations and guidance, including environmental requirements. The City did not follow environmental requirements or effectively manage its CHDOs. The City did not always (1) complete an environmental review or obtain HUD approval before committing funds, (2) maintain environmental review documentation, exercise due diligence or (3) properly administer its CHDO program in accordance with requirements. These conditions occurred because the City did not fully understand or follow HUD environmental or HOME regulations and its own policies, procedures, and contract terms. As a result, it misspent more than $6.6 million and did not account for more than $180,000 in program income. We recommended that the Director of the Fort Worth Office of Community Planning and Development require the City to (1) repay approximately $2.4 million in funds committed before completion of an environmental review or HUD approval; (2) support or repay $424,325 in fund committed to projects without environmental reviews; (3) support or repay more than $3.8 million for unsupported files and draws; (4) support or repay $180,051 in program income; (5) repay $13,055 in ineligible costs; and (6) strengthen its underwriting procedures and implement documentation, homebuyer income verification, and CHDO recertification procedures.