Federal Reports

The Office of Inspector General (OIG) has identified significant vulnerabilities in the Medicare hospice benefit and found that hospices did not always provide needed services to beneficiaries and sometimes provided poor quality care. Hospice care can provide great comfort to beneficiaries, their families, and other caregivers at the end of a beneficiary's life. To promote compliance and quality of care, the Centers for Medicare & Medicaid Services (CMS) relies on State agencies and accrediting organizations to survey hospices. As part of this process, surveyors review clinical records, visit patients, and cite hospices with deficiencies when they do not meet Medicare requirements. Hospices must be surveyed at least once every 3 years. Surveyors also investigate complaints. This report provides a first-time look at hospice deficiencies nation-wide in that it includes both hospices that were surveyed by State agencies and those surveyed by accrediting organizations. This report is the first in a two-part series. The companion report addresses beneficiary harm in depth.

The VA Office of the Inspector General (OIG) conducted this audit to follow up on previous reviews of its capital asset programs, which have identified areas of improvement for both major and minor construction projects, and to determine whether VA effectively managed the procurement and awarding of major medical leases under the Veterans Access, Choice, and Accountability Act of 2014 (VACAA). The OIG found that VA major medical leases authorized by VACAA are approximately 22 months behind schedule on average. The management structure of the lease acquisition process spans multiple lines of authority and requires many decisions to execute a lease contract. As a result, lease acquisitions are often slowed when project managers are confronted with conflicting opinions from different management groups. VA has taken some steps to improve the major lease acquisition process, including simplifying the solicitation documentation to better align with General Services Administration practices and changing VA’s mission-critical building standards for leases to better align with similar private sector facilities. However, several of the recommendations remain unaddressed. The OIG recommended VA ensure there are adequate funds available to routinely conduct planning activities including developing requests for lease proposals while waiting for congressional authorization; reconsider centralizing major medical lease acquisition funding activities, make certain adequate resources are available to deliver leases on schedule; ensure that the prospectus cost estimates provided to Congress are accurate; establish clear lines of authority for critical lease acquisition decisions; and adhere to appropriate security measure requirements by performing Interagency Security Committee risk evaluations prior to solicitation. Implementing these recommendations should result in faster and more cost-efficient acquisition of major medical leases.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to allegations related to the discharge of a patient from an inpatient mental health unit at a Veterans Integrated Service Network 4 Medical Facility. The patient was arrested by VA Police, discharged to a federal detention center (FDC), and died eight days later. The OIG identified concerns related to discharge planning processes, voluntary and involuntary admission, use of guidance regarding the patient’s legal and psychiatric status, and patient record flag management. The OIG did not substantiate that the patient died by suicide in the FDC. The Associate Medical Examiner identified the cause of death as hypertensive and atherosclerotic cardiovascular disease and the manner of death as natural. The OIG substantiated that facility staff failed to engage in proper treatment and discharge planning processes. Specifically, staff failed to: • Include the patient and family in treatment and discharge planning, • Address the patient’s decision-making capacity, • Identify and consistently document the patient’s surrogate, • Provide clinical hand-off communication to the receiving mental health providers, despite the patient’s medical and psychiatric acuity and complex medication regimen, • Assign a mental health treatment coordinator, • Obtain a release of information for the VA Police to obtain discharge information, • Obtain consent for voluntary admissions from the surrogate for patients who lack decision-making capacity, and • Consider accessing expert consultative resources to prepare more effectively for patient treatment and discharge. The OIG made 10 recommendations related to inclusion of family in inpatient mental health treatment and discharge planning; assessment of decision-making capacity and voluntary admission status; documentation of a patient’s surrogate; provision of a complete diagnostic summary to receiving providers; assignment of a mental health treatment coordinator; release of information processes; inpatient mental health unit voluntary and involuntary admission processes; and access to consultative resources.

During the week of June 10, 2019, we visited five Border Patrol stations and two ports of entry in the Rio Grande Valley sector and observed serious overcrowding and prolonged detention of children and adults that require immediate attention. Specifically, Border Patrol facilities in the Rio Grande Valley do not have the capacity to hold the thousands currently in custody, and have been holding hundreds of children in custody beyond the 72 hours generally permitted under the TEDS standards and the Flores Agreement.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the James H. Quillen VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. At the time of the review, 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 executive leadership team appeared stable, with three of the four positions permanently filled for over one year prior to the OIG’s on-site visit. Selected survey scores related to employees’ satisfaction and trust in the facility’s executive leaders were better than VHA averages. Patient experience survey data revealed that scores related to satisfaction with the facility were above VHA averages. The OIG’s review of the facility’s accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “2-star” quality ratings. The OIG issued five recommendations for improvement in the following areas: (1) Medication Management: Controlled Substances Inspections • Completion of inspections on day initiated • Reconciliation of dispensing and return of stock for one random day • Emergency drug cache inspections (2) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education on medications