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 Central Arkansas Veterans 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 (CS) 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 Facility had generally stable executive leadership and active engagement with employees as evidenced by satisfaction scores. However, opportunities exist to improve patient experiences. Facility leaders appear to support patient safety, quality care, and other positive outcomes. The OIG reviewed accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results and 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 performance of Quality of Care and Efficiency metrics likely contributing to the current “2-Star” rating. The OIG noted findings in five of the eight areas of clinical operations reviewed and issued nine recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Physician Utilization Management Advisors’ documentation of decisions (2) Environment of Care • Panic alarm testing at the representative community based outpatient clinic and locked mental health unit (3) Medication Management: CS Inspection Program • Monthly reports to the Director • CS reconciliation • CS order verification • Emergency drug cache inspections (4) Mental Health Care: Post-Traumatic Stress Disorder Care • Suicide risk assessments (5) Long-term Care: Geriatric Evaluations • Program oversight

We found that the post’s financial and administrative operations required significant improvement to comply with agency policies and applicable Federal laws and regulations. Our report contains 25 recommendations directed to both the post and headquarters. At the post, our recommendations included strengthening controls over managing imprest funds, bills of collections, security certifications, and Volunteer payments; ensuring collection of all necessary receipts to claim value added tax refunds; and ensuring proper management oversight of grants, vouchers, and credit cards. Management concurred with all 25 recommendations.

An Amtrak Extra Board Lead Service Attendant in Chicago, Illinois, was terminated from employment on August 23, 2018, following an administrative hearing for violating company policy by stealing company funds and financial paperwork, wrongfully engaging in outside employment while on medical leave, and failing to cooperate with the OIG during the investigation.Our investigation revealed that the employee stole approximately $2,418.25 in cash and/or the cash equivalent value of unaccounted for/missing inventory. Additionally, we found that the employee worked at a local university while on medical leave from the company. Criminal judicial proceedings related to this case are pending in the Circuit Court of Cook County, Illinois.Amtrak OIG conducted this joint investigation with the Amtrak Police Department.Date Posted:

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations that the Samuel S. Stratton VA Medical Center’s peer review processes did not follow Veterans Health Administration (VHA) policy; the surgeon performed intraoperative radiofrequency ablation (IORFA) surgery for hepatocellular carcinoma and “completely missed” tumors in patients; a surgeon told a patient there was a recurrence of a tumor although it was “completely missed” during IORFA surgery; the surgeon performed cancer surgery on patients who did not have cancer; and adverse events occurred during and after the surgeon’s other cancer surgeries. The OIG substantiated the facility’s peer review process did not follow VHA policy, and the facility did not meet credentialing and privileging requirements. The OIG substantiated the surgeon completely or partially missed tumors when performing IORFA in three patients and told patients they had residual tumors when tumors were not initially ablated. The OIG determined that facility leaders did not provide disclosures for the patients reviewed. The OIG did not substantiate the surgeon performed surgery on patients who did not have cancer or that adverse events occurred during cancer surgeries. The OIG made nine recommendations related to reviewing quality oversight and quality data for professional practice evaluations; improving peer review programs; including accurate performance data for Surgery Service’s professional practice evaluations; developing and implementing processes to document, report, and track discussed patient cases; implementing processes to track, monitor, and report IORFA outcomes; consulting with Office of General Counsel on patients with missed tumors to institutionally disclose if appropriate; assessing the Surgeon’s IORFA outcomes; performing external reviews of IORFA processes; and evaluating actions for relevant staff.