Federal Reports

The grant provided ARC funding to support Bevill State Community College (BSCC) in operating the Alabama Appalachian Higher Education (AAHE) Center and implementing project to improve the post-secondary education levels in distressed areas of six Western Alabama counties.

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 Dayton VA Medical Center, Ohio (Facility). 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 Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. Three of four Facility leadership positions were filled by interim or acting staff, with long-term Facility leaders in two positions. Organizational leaders supported patient safety and quality care. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the current “4-Star” rating. The OIG noted findings in four of eight areas of clinical operations reviewed and issued 10 recommendations attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies were: (1) Quality, Safety, and Value • Completion of inpatient admissions and continued stay reviews • Physician Utilization Management (UM) Advisors’ documentation of decisions • Interdisciplinary review of UM data (2) Credentialing and Privileging • Focused Professional Practice Evaluation processes (3) Environment of Care • Completion of Environment of Care (EOC) rounds • Facility cleanliness and maintenance • Medical equipment safety inspections (4) Long-term Care: Geriatric Evaluations • Program oversight and evaluation • Medical evaluation • Implementation of interdisciplinary plan of care

The VA Office of Inspector General (OIG) conducted a rapid response healthcare inspection after an OIG Comprehensive Healthcare Inspection Program review identified several significant environment of care (EOC) deficiencies at the McComb Community Based Outpatient Clinic (CBOC) on May 23, 2018. The purpose of the inspection was to assess EOC conditions at the remaining six contract CBOCs under the auspices of the G.V. (Sonny) Montgomery VA Medical Center (Facility) in Jackson, Mississippi. On May 30, three OIG teams conducted unannounced inspections at the Columbus, Greenville, Hattiesburg, Kosciusko, Meridian, and Natchez, Mississippi, CBOCs. OIG inspectors did not identify deficiencies related to general privacy requirements or the availability of medical equipment and supplies. The OIG inspectors found general safety, medication safety and security, infection prevention and environmental cleanliness, and information technology deficiencies. While OIG inspectors did not find that those conditions placed patients or staff at risk, corrective actions were needed to ensure a clean, healthy, and safe environment for patients and staff. The OIG team found inconsistencies between the requirements for Veterans Health Administration oversight as described in the respective CBOC contracts, the Contracting Officer’s Representative expectations, and Facility managers’ approach to CBOC site visits. In addition, when Facility managers conducted CBOC inspections, they did not consistently keep written records of what was reviewed, deficiencies found, or required dates for correction. The OIG team briefed Facility leaders on the results of the inspection findings on June 7, 2018. The OIG made two recommendations related to Facility comprehensive reviews of environment of care issues and consistent oversight of the CBOC operations.

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 VA Ann Arbor Healthcare System (Facility). 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 Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The OIG also provided crime awareness briefings to 124 employees. The Facility has a relatively new executive leadership team that appears stable and actively engaged with employees and patients. The executive leaders support efforts related to patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the Facility through active stakeholder engagement). The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to maintain care and performance of selected SAIL metrics likely contributing to the current “4-Star” rating. The OIG noted findings in three of the eight areas of clinical operations reviewed and issued three recommendations that are attributable to the Director, Chief of Staff, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations (2) Environment of Care • Environment of care rounds attendance (3) Medication Management: Controlled Substances (CS) Inspection Program • Reconciliation of CS dispensing and return of stock

An Amtrak Trainmaster was terminated from his position on August 14, 2018, and an Amtrak executive resigned from his position in lieu of termination on August 17, 2018. The Chicago-based employees violated company policy by accepting gifts from the owner of a firm doing business with Amtrak and by intentionally providing false or misleading information to the Amtrak Office of Inspector General.

During an interview related to the Fiscal Year 2018 Financial Statement Audit, a United States Capitol Police (USCP or the Department) official informed the Office of Inspector General (OIG) of a Civilian Employee Handbook, dated March 7, 1997, which the USCP is still distributing to new civilian employees.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of inpatient and outpatient care delivered at the Beckley VA Medical Center (Facility). 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 Inspection Program; Mental Health Care: Post-Traumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The leadership team appears stable with the hiring of the Chief of Staff and Associate Director in November 2017. The leaders are committed to continuous active engagement with employees and patients. The OIG’s review did not identify any substantial organizational risk factors. However, the OIG noted that the Facility appears to have opportunities to improve the reporting and tracking of sentinel events. The senior leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics and should continue to take actions to improve performance of selected Quality of Care and Efficiency metrics likely contributing to the most current “3-Star” rating. The OIG noted findings in five of the eight areas of clinical operations reviewed and issued eight recommendations that are attributable to the Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluation processes (2) Environment of Care • Frequency, participation, and documentation of Environment of Care rounds (3) Medication Management: Controlled Substances Inspection Program • Correction of annual physical security survey deficiencies • Verification of controlled substances orders (4) Women’s Health: Mammography Results and Follow-Up • Mammography results electronically linked to the radiology order (5) High-Risk Processes: Central Line-Associated Bloodstream Infection • Staff training

The Office of the Inspector General audited the network architecture of a nuclear facility to determine if the network architecture and assets in use to support a specific nuclear plant’s business and operational functions are compliant with TVA policies, procedures and identified best practices. In summary, we found TVA management used proven best practices in the design of the corporate physical and wireless networks and the control network. However, we found cabling that was not following manufacturer’s guidelines and several control network device configurations deviated from TVA baselines and industry best practices. TVA management agreed with our findings and recommendations.