Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the William S. Middleton Memorial Veterans Hospital. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health: Posttraumatic Stress Disorder; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results; and High-risk Processes: Central Line-associated Bloodstream Infections. The Facility had stable executive leadership and active engagement with employees and patients. The OIG reviewed accreditation agency findings, adverse events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors. The OIG noted findings in two of the eight areas reviewed and issued four recommendations attributable to the Director and the Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (2) Medication Management: CS Inspection Program • CS Inspectors free of conflicts of interest • Reconciliation of CS return to stock • Verification of drugs held for destruction

Of the 120 sampled outpatient claims totaling $415,513, First Coast Service Options, Inc. (First Coast) made payments for hyperbaric oxygen (HBO) therapy in accordance with Medicare requirements for 5 claims. However, First Coast made payments for HBO therapy that did not comply with Medicare requirements for 110 claims (92 percent), resulting in overpayments for HBO therapy totaling $351,970. We did not review the remaining five claims because one was canceled and the Recovery Audit Contractor indicated that the other four were under review by another entity.

OIG performed an audit of the National Oceanic and Atmospheric Administration's Pacific Coastal Salmon Recovery Fund Grants awarded to the Washington State Recreation and Conservation Office (RCO). The objectives of our audit were to determine whether RCO (1) claimed allowable, allocable, and reasonable costs, (2) complied with grant terms and conditions, administrative requirements, cost principles, and audit requirements, and (3) met performance requirements of the grants.

An Amtrak Service Engineer resigned from employment on December 20, 2018, following a joint investigation with the Metropolitan Transportation Authority (MTA) OIG which revealed the employee simultaneously worked at both Amtrak and New York’s MTA. The employee failed to disclose his dual employment on Amtrak’s Certificate of Compliance form. When confronted with the investigation’s findings, the employee immediately resigned from the Amtrak.

The OIG investigated multiple allegations of improper hiring, noncompetitive promotions, nepotism, favoritism, and other improper personnel practices by three Bureau of Safety and Environmental Enforcement (BSEE) senior officials.We found that one of the officials violated Federal regulations when he pursued a procurement action to hire an employee with whom he had a prior relationship. We also found that he directed a change to the minimum qualification language in a job solicitation to aid the same employee’s selection for Federal employment. We found no evidence to support the allegations against the other two officials involving hiring, noncompetitive supervisory reassignments, nepotism, or favoritism.We found that a BSEE official violated Federal regulations when he pursued a procurement action to hire an employee with whom he had a prior relationship.