Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Manila Outpatient Clinic, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s leaders had been working together for two years, although the clinic manager (director) had served in the position for many years. The facility’s leadership team appeared relatively stable; however, a new director was scheduled to assume duties one week after the OIG’s on-site visit. Selected employee satisfaction survey results, except that for the director regarding servant leadership, indicated that leaders were engaged and promoted a culture of safety where employees feel safe bringing forward issues and concerns. The selected patient experience survey scores for facility leaders were better than the VHA average. Additionally, the OIG reviewed accreditation agency findings, sentinel events, and disclosures of adverse patient events and did not identify any substantial organizational risk factors. However, the impact of political unrest in the Philippines may affect access to care and safety of veterans and staff. The OIG issued seven recommendations for improvement: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluations (2) Controlled Substances Inspections • Pharmacy inspection inventory counts (3) Military Sexual Trauma (MST) Follow-up and Staff Training • Communicating the status of MST services with leaders • Tracking MST-related data • Completing timely diagnostic treatment evaluations (4) Antidepressant Use among the Elderly • Patient/caregiver education on newly prescribed medications • Medication reconciliation

The VA Office of Inspector General (OIG) evaluated the oncology service staff’s adherence to the facility’s psychosocial distress screening standard operating procedure in the care of two patients who died by suicide, and facility leaders’ response to the root cause analyses following the two patients’ deaths. Facility oncology service staff demonstrated compliance with psychosocial distress screening standard operating procedures. However, the OIG was unable to determine if a mental health evaluation completed prior to one of the patients leaving the clinic would have changed the patient’s outcome. Completion of a mental health evaluation may have identified additional risk factors and provided opportunity for suicide prevention interventions prior to the patient leaving the clinic. The National Comprehensive Cancer Network standards of care state a patient should be screened at the initial visit and ideally at every visit. Facility oncology service nursing staff were unclear about when to administer the psychosocial distress thermometer, a self-report tool that evaluates a patient’s distress level, and therefore, administered the tool at every visit. Thus, nursing practice in the facility oncology service exceeded the facility standard operating procedure requirements and provided the National Comprehensive Cancer Network ideal standard of care. The alignment of the standard operating procedure with the ideal standard and current practice is critical to ensure clear guidance to staff regarding the completion of the psychosocial Distress Thermometer. The facility’s Patient Safety Manager did not monitor progress toward root cause analysis action item completion. Following the OIG team’s expressed concern about this deficiency, the Patient Safety Manager implemented a tracking tool that same month. The OIG identified one additional concern. After a patient’s death by suicide in 2017, the Acting Suicide Prevention Coordinator did not complete a Suicide Behavior Report or Behavioral Health Autopsy, as required by Veterans Health Administration.

We reviewed FSIS’ compliance with CIS program requirements for the interstate shipment of certain State-inspected meat and poultry products.

In accordance with our annual plan, the Office of Inspector General (OIG) assessed the United States Capitol Police (USCP or Department) Pre-screener Program to determine whether (1) the organizational structure and training for the program was the most efficient and effective, and (2) the Department complied with applicable policies and procedures as well as applicable laws, regulations, and best practices. Our scope included the Pre-screener Program organizational structure, training, and compliance with policies and procedures.

We investigated an allegation that Secretary of the Interior David Bernhardt, when he was the Deputy Secretary, interfered with the U.S. Fish and Wildlife Service’s (FWS’) scientific process during an assessment of the effects of pesticides on endangered species. We investigated whether Secretary Bernhardt exceeded or abused his authority by influencing consultations between the FWS and the U.S. Environmental Protection Agency on the proposed registration or re-registration of three pesticides, and whether his involvement in the consultations violated his ethics pledge or Federal ethics regulations.We found that Secretary Bernhardt reviewed a draft FWS opinion on the potential biological effects one of the three pesticides could have on endangered species, and he instructed the FWS team developing the opinion to change its method for determining the potential effects. This change has delayed the completion of the opinion, but we found no evidence that Secretary Bernhardt exceeded or abused his authority or that his actions influenced or altered the findings of career FWS scientists. We also found no evidence that Secretary Bernhardt’s involvement in this matter violated his ethics pledge or Federal ethics regulations.On January 7, 2021, this report was corrected to remove an inaccurate footnote. This correction did not affect our findings.