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 Tomah 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; and Womens Health: Mammography Results and Follow-Up. The OIG also provided crime awareness briefings to 74 employees. The Facility currently has stable executive leadership and active engagement with employees and patients, as evidenced by satisfaction scores. The leaders are improving patient satisfaction and had expanded selected programs and services. However, the OIG noted deficiencies with the Leadership Quality Council’s multidisciplinary team review and analysis of aggregated data. The OIG’s review of accreditation organization findings, sentinel events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected SAIL metrics, particularly Quality of Care and Efficiency metrics likely contributing to the “3-Star” rating. The OIG noted findings in one area of clinical operations reviewed and issued two recommendations. The identified area with deficiencies are: Medication Management: Controlled Substances Inspection Program • Annual physical security survey deficiencies • Controlled substances reconciliation

Some of the bonus payments that Alaska received for the audit period were not allowable in accordance with Federal requirements. Most of the data used in Alaska’s bonus payment calculations were in accordance with Federal requirements. However, Alaska overstated its fiscal years 2009 through 2013 current enrollment in its bonus requests to the Centers for Medicare & Medicaid Services (CMS) because it included individuals who did not qualify because of their basis-of-eligibility (BOE) category. CMS guidance instructed States to include in their current enrollment only individuals whom the State identifies and reports as having a BOE of "child" in the Medicaid Statistical Information System, which are BOE categories 4, 6, and 8. In addition to these three BOE categories, Alaska incorrectly included individuals from BOE 2, "Blind and Disabled."

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of Chillicothe 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; and Women’s Health: Mammography Results and Follow-Up. The Facility has stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders appear to support 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, and Patient Safety Indicator data results did not identify any substantial organizational risk factors. Although the leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning metrics and the Facility was rated as “5 Stars” for overall quality, the leaders should continue to take actions to sustain performance and to improve care and performance of poorer performing Quality of Care and Efficiency metrics. The OIG noted findings in two of the seven areas of clinical operations reviewed and issued two recommendations that are attributable to the Chief of Staff. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations (2) Women’s Health: Mammography Results and Follow-Up • Electronic linking of mammogram results to the radiology order

HHS oversees States’ use of various Federal programs, including Medicaid. State agencies are required to establish appropriate computer system security requirements and conduct biennial reviews of computer system security used in the administration of State plans for Medicaid and other Federal entitlement benefits (45 CFR § 95.621). This review is one of a number of HHS, Office of Inspector General, reviews of States’ computer systems used to administer HHS-funded programs.

DHS did not comply with the Improper Payments Elimination and Recovery Act (IPERA) because it did not meet one of the six IPERA requirements. Specifically, DHS did not meet its annual reduction targets for 2 of 14 programs. Additionally, we determined that DHS did not provide adequate oversight of the component’s improper testing and reporting.

This report presents the results of our audit to assess management’s corrective action to address mail delivery issues for customers serviced by the Cimarron Hills Station . The Cimarron Hills Station is in Colorado Springs, CO, in the Colorado/Wyoming District, Western Area. This audit was initiated at the request of Congressman Doug Lamborn, 5th Congressional District, Colorado. The inquiry showed that residents of two neighborhoods serviced by the Cimarron Hills Station — Indigo Ranch and Stetson Hills — were dissatisfied with their delivery service and experienced frequent misdelivery of mail and missing items.

The VA Office of Inspector General (OIG) Administrative Investigations Division investigated an allegation that a Supervisory Industrial Engineer misused VA time and resources to start a privately-owned business and solicited subordinate staff to join this business. The OIG found that the Engineer, who worked within the Veterans Health Administration, Office of Strategic Integration, Veterans Engineering Resource Center (VERC), used a VA-assigned email account to communicate with subordinate staff, criticize the recent VERC restructuring, and propose they, as a team, use their experience to create a company that offered those services to outside organizations. The Engineer then created a company in the midst of discussions of potential layoffs within the VERC. The Engineer assumed the president position, and two other VERC employees became the director and treasurer. The OIG found they misused VA time and resources to conduct non-VA business during and after their official duty hours. The OIG also found that the company, at one point, consisted of up to 43 VA employees. Most of those employees have since left VA as their term appointments ended or were scheduled to end without extension. Further, the OIG found that the Engineer misused a VA-assigned email on several occasions to manage multiple personally-owned rental properties.