Federal Reports

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Central Ohio Health Care System in Columbus. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued three recommendations for VA to correct identified deficiencies in three domains:
   1.    Culture
     •    Standardized process for service-level communication
   2.    Environment of care
     •    Clean patient areas and intact walls
   3.    Veteran-centered safety net
     •    Housing and Urban Development–Veterans Affairs Supportive Housing program resources

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Southern Nevada Healthcare System (facility) in Las Vegas to analyze facility leaders’ response to allegations that a dental hygienist failed to follow Veterans Health Administration and facility policies and provide quality care. The OIG determined that supervisors did not ensure the correction of patient safety concerns related to the dental hygienist’s practice after having knowledge of the repeated concerns for approximately two years. 

A supervisor requested a factfinding, which substantiated the dental hygienist falsified a patient’s electronic health record; however, the falsification went unaddressed. The factfinding was not completed timely and, although requested, a review of two medication storage violations was not included. Additionally, a supervisor considered but did not implement a performance improvement plan to address repeated clinical practice concerns and infection control violations. 

Due to conflicting recollections, the OIG was unable to determine whether a supervisor recommended a comprehensive review of the dental hygienist’s care to the credentialing and privileging manager, which is a step in the state licensing board (SLB) reporting process. Also, on the provider exit review form, a supervisor did not accurately reflect clinical care concerns regarding the dental hygienist. An accurate form would have prompted initiation of the SLB reporting process. Further, supervisors did not ensure that patient safety reports were submitted through the Joint Patient Safety Reporting system as required. 

The OIG determined that the Chief of Staff (COS) did not consider a management review of the dental hygienist’s care after receiving a recommendation from a risk manager to conduct a management review. The COS also did not effectively utilize high reliability organization principles to become aware of the full extent of patient safety concerns regarding the dental hygienist. 

The OIG made eight recommendations to the Facility Director.

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The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

Why We Did This Report

In response to a congressional request, our objective was to determine whether the fiscal year 2021 Environmental Justice Collaborative Problem-Solving, or EJCPS, Program was achieving project objectives and whether the U.S. Environmental Protection Agency’s monitoring of these projects ensured that funds were used as intended.

Summary of Findings

We were unable to determine whether the EJCPS cooperative agreements we reviewed fully achieved the project objectives described in work plans, as well as whether the EPA’s monitoring of these projects ensured that the funding was being used as intended. Specifically, (1) four of six work plans did not consistently contain well-defined measurable outputs and expected outcomes, (2) three of six recipients’ performance reports lacked details to fully measure progress, and (3) the project officers for four of six projects did not document their review of recipients’ performance reports.