Federal Reports

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OIG conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Southern Oregon Rehabilitation Center and Clinics (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Environment of Care; Long-Term Care: Community Nursing Home Oversight; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 64 employees.The facility has opportunities to improve the stability of executive leadership and patient satisfaction. However, OIG’s review of accreditation organization findings, sentinel events, disclosures, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was generally knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 1-star rating.OIG noted findings in five areas of clinical operations reviewed and issued eight recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Root cause analyses completion(2) Medication Management: Anticoagulation Therapy• Quality assurance data reviews(3) Environment of Care• Environment of care rounds attendance(4) Long-Term Care: Community Nursing Home Oversight• Oversight committee membership and attendance• Cyclical clinical visits(5) Mental Health Residential Rehabilitation Treatment Program• Weekly contraband inspections• Closed circuit television surveillance system• Signage to alert patients and visitors of recording.

The Office of Inspector General assessed efforts of the Center for Advancement of Science in Space (CASIS) to manage non-NASA research on the U.S. portion of the International Space Station known as the National Lab.

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We received hotline complaints detailing concerns related to Spectrum 4’s acquisition and performance. We initiated a limited scope review to determine the legitimacy and severity of these issues. We substantiated some of the issues, and they warrant management’s attention. Specifically, we found the deployment of Spectrum 4 resulted in increased errors/variances, which required PBGC to release ten versions in attempts to fix the issues causing the errors. We also found that the deployment of Spectrum 4 resulted in slower day-to-day functioning of the system. This slowness has impacted users’ ability to complete tasks and frustrated users. In response to the issues we substantiated, we recommend that management perform and document an Integrated Product Team led “lessons learned”.