Federal Reports

Please click the link below to access a press release describing this and other related documents.

Please click the link below to access a press release describing this and other related documents.

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 Illiana Health Care System (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value (QSV); Environment of Care (EOC); 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 Central Line-Associated Bloodstream Infections special focus area did not apply as the Facility did not have an intensive care unit or emergency department; thus, the OIG focused on the remaining seven areas of clinical operations. The OIG also provided crime awareness briefings to 188 employees. The Facility has generally stable executive leadership and active engagement with employees and patients as evidenced by patient and employee satisfaction scores. Organizational leaders support patient safety, quality care, and initiation of processes and plans to maintain 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 results did not identify any substantial organizational risk factors. The OIG noted findings in five of the seven areas of clinical operations reviewed and issued seven recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluation completion (2) QSV • Utilization Management Committee attendance (3) EOC • EOC rounds attendance • Temperature monitoring in all dry food storage areas (4) Medication Management: Controlled Substances Inspection Program • Staff access to monthly electronic inventory balance adjustments (5) Women’s Health: Mammography Results and Follow-Up • Results electronically linked to radiology order • Communication of test results to patients

We evaluated TVA’s fuel cost adjustment (FCA) calculations to determine whether TVA was using the appropriate data to calculate the FCA. We determined TVA was not using the appropriate sales data to calculate the FCA due to (1) inaccurate unbilled energy sales, (2) the misclassification of sales made to small direct-served customers, and (3) inaccurate hourly energy loads. In addition to the errors identified, we also determined the FCA process could be improved to reduce the risk of errors in the FCA. Specifically, the FCA process is reliant on many hand offs, manual calculations, queries, and complex spreadsheets. Further heightening the risk of error, we found TVA’s FCA process was not documented.

The VA Office of Inspector General (OIG) assessed the effectiveness of the Oklahoma City VA Health Care System’s (Health Care System) oversight of its disbursement agreement and time and attendance for part-time physicians. The OIG found that Health Care System managers did not monitor resident participation to ensure they were performing VA work as scheduled or ensure part-time physicians met their employment obligations. This occurred in part because former leaders of the Health Care System did not establish an effective governance environment. The OIG also found the Health Care System lacked required local policies and procedures for resident educational activity record keeping, did not adequately monitor resident participation in educational activities, and did not reconcile educational activity records with invoices submitted by the University of Oklahoma College of Medicine—the affiliated medical school. In addition, former Health Care System directors did not appoint a team to conduct required periodic audits of the disbursement agreement. As a result, the Health Care System could not provide adequate supporting documentation to substantiate its reimbursement payments for residents. Therefore, the Health Care System’s approximately $6.9 million in reimbursements to the medical school during academic year 2015–2016 are considered improper payments. In addition, there was no assurance the Health Care System received all of the resident services that it paid for. Health Care System managers also did not effectively oversee time and attendance for part-time physicians because they did not monitor time and attendance and ensure part-time physicians recorded work hours daily in the system. Because the Health Care System did not reconcile payments made to part-time physicians on adjustable work schedules with their actual work performance, it made approximately $507,000 in improper payments and there was no assurance that these physicians were fully meeting their VA employment obligations.