Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Sheridan VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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 were stable and actively engaged with employees and patients; and, upon review of the facility’s accreditation organization findings, sentinel events, disclosures, and patient safety indicators, the OIG did not identify any substantial organizational risk factors. However, the facility had a repeat finding with ongoing professional practice evaluations. The senior leaders were knowledgeable about selected SAIL and CLC metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “1-star” quality ratings. The OIG issued 22 recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Infection control and general cleanliness • Mental health unit panic alarm testing response times • Mental health unit seclusion room flooring • Emergency generator testing (3) Controlled Substances Inspections • Reconciliation of dispensing and return of stock • Controlled substances order verifications • Routine inspections by controlled substances coordinators (4) Military Sexual Trauma (MST) Follow-up and Staff Training • Providers’ training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) Emergency Departments and Urgent Care Centers • Waiver for 24-hour operations • Staffing and call schedules • Use of required tracking program • Directional signage • Equipment/supply availability

The VA Office of Inspector General (OIG) conducted an inspection to review an allegation of poor quality of cancer care to a community living center (CLC) patient, and to follow up on the adequacy and implementation status of action plan items to address deficiencies identified by Veteran Integrated Network (VISN) 8 reviewers related to the care of 55 patients at the VA Caribbean Healthcare System (facility) in San Juan, Puerto Rico. The OIG substantiated that staff inadequately monitored the CLC patient. Documentation was insufficient and there were no care coordination agreements between the CLC and other services. Licensed practical nurses did not add registered nurses as co-signers to notes to alert them of changes in the patient’s status, and the patient’s care plan had not been modified to include the initiation of chemotherapy. The OIG found that action plan items did not comprehensively address all findings identified by non-facility VISN reviewers. While not an allegation, the OIG found that VISN 8 had contracted with a non-Veterans Health Administration reviewer to independently review eight patient cases for interrater reliability; however, the information provided to the interrater reviewer was not identical to the information provided to the non-facility VISN reviewers. The OIG made one recommendation to the VISN Director related to clear and consistent instructions for concurrent management reviews and six recommendations to the Facility Director related to the monitoring of chemotherapy patients, care coordination agreements between the CLC and specialty services, utilization of procedures regarding the communication of patient status changes, completion and accuracy of patient care plans, primary care provider training on prostate cancer patient management, and addressing the findings of the non-facility VISN reviewers.

Christian Newby, 31, of Milan, Michigan, pleaded guilty in the Eastern District of Michigan to charges of wire fraud, unlawful possession of a firearm by a drug user, and aggravated identity theft on August 14, 2019. As part of the plea agreement, Newby agreed to a forfeiture amount of $550,000, and to forfeit jewelry, gold and silver coins, and various weapons and ammunition.Our investigation disclosed that Newby participated in a scheme to defraud Amtrak and others by using stolen credit card information from more than 1100 credit cards to purchase Amtrak tickets online. Newby then cancelled the Amtrak tickets and received vouchers for the value of those tickets from Amtrak. Newby sold the Amtrak vouchers on eBay at a fraction of their face value. As a result, Newby fraudulently caused Amtrak to issue more than $540,000 in ticket vouchers.Newby was arrested on January 31, 2019, and a search warrant was executed at Newby’s residence. The search resulted in the seizure of cash, jewelry, gold and silver coins, counterfeit identification and credit cards, semi-automatic weapons with high-capacity magazines, armor piercing ammunition, and numerous pipe bombs and improvised explosive devices.Newby will be sentenced at a future date.

In 2016, TVA implemented an individual performance multiplier (IPM) that allows managers to adjust employees’ annual Short-Term Incentive lump-sum payouts based on performance. Since alignment between the multiplier and performance are important to the success of the initiative, we scheduled an evaluation of TVA’s IPM. Our objective was to determine if IPMs were in alignment with performance ratings. We reviewed 5,235 adjustable payouts made in fiscal years 2017 and 2018, and found most of the IPM adjustments were in alignment with overall performance ratings. However, 59 adjustments made in fiscal years 2017 and 2018 fell outside the recommended ranges established in the IPM guideline. We determined some of these happened because the IPM process uses rounded overall performance ratings instead of actual calculated performance ratings.

The Mainframe Applications Re-platform Initiative at the Railroad Retirement Board is Progressing in Accordance with Established Project Goals