Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation of delays in diagnosis of a patient’s cancer at a Veterans Integrated Service Network 15 medical facility. The OIG substantiated a delay in the patient’s diagnosis. The patient’s initial complaint and abnormal computed tomography scan were in summer 2016, but a complete evaluation did not occur until spring 2018 when the patient was diagnosed with cancer. The patient completed suicide prior to treatment. The OIG identified multiple deficiencies in the coordination of the patient’s care between and among several primary and specialty care providers, changes in providers or assignments of surrogate providers, receipt of automated electronic notifications (view alerts) for imaging study abnormalities, and communication of abnormal test results to the patient that contributed to the delayed diagnosis. Facility leaders did not perform an institutional disclosure and conducted a prospective internal review rather than a retrospective analysis for adverse clinical events as required by the Veterans Health Administration. The OIG made eleven recommendations related to the planning and implementation of the new electronic health record, review of the patient’s clinical care, Patient Centered Management Module and provider assignments, designation of surrogates, view alerts, secure messaging communication, patient notification of test results, disclosures, and quality management activities related to internal reviews.

The VA Office of Inspector General (OIG) performed this review as required by the VA MISSION Act of 2018. VA has experienced chronic healthcare professional shortages since at least 2015, and the law requires annual reporting on steps taken to achieve full staffing and the additional funds needed to achieve that level. The law also requires VA to publicly release quarterly staffing and vacancy data. The OIG found VA partially complied with the law’s requirements, reporting current personnel and time-to-hire data as prescribed. However, VA’s initial reporting of staff vacancies and employee gains and losses was not transparent enough to allow stakeholders to track VA’s progress toward full staffing. This lack of compliance, if not corrected, may impact the transparency of VA’s future staffing and vacancy reporting. VA also did not follow specifications for reporting gains and losses quarterly as required, instead reporting annually without public explanation. VA should adjust its methodology for aggregating gains and losses to ensure data are reported appropriately and transparently. The OIG team identified opportunities for VA to improve its data reporting. VA’s public website only reported data for the current quarter and did not maintain historical versions of the published data. The overall transparency of VA’s staffing and recruitment website would be improved by maintaining historical data for public review. The OIG also found labeling errors in the reported information, indicating opportunities to improve the review process before publication. However, the OIG noted VA’s improvements in its administration of the reporting process which allowed for more precise quality reviews and greater assurance that the published data were accurate. The OIG recommended the Assistant Secretary for Human Resources and Administration ensure that staffing and vacancy data are reported as required, disclose limitations in the data, maintain historical data publicly, and update the methodology.

What We Looked AtEffective drug and alcohol testing programs in the transportation industry are critical to ensuring the safety of the traveling public. The National Transportation Safety Board recently highlighted this issue in its 2017-2018 Most Wanted List of Transportation Safety Improvements, stating that various issues have led to an epidemic of impairment in transportation. Given this important safety concern, our office initiated a series of reviews on drug testing programs within the Department of Transportation, beginning with this audit of the Federal Aviation Administration (FAA). Our objective was to assess the effectiveness of FAA's inspection program. Specifically, we evaluated FAA's risk-based approach for prioritizing and selecting companies for inspection and the basis for the risk factors used.What We FoundThe system FAA uses to develop inspection schedules does not assign risk levels to companies or prioritize inspections based on risk--contrary to FAA's Safety Risk Management Policy, which was implemented to identify hazards, analyze and assess safety risk, and develop controls. Instead, FAA judgmentally selects where and when to conduct drug and alcohol inspections based on available inspection resources, company location, and FAA's desire to conduct as many inspections as possible. Also, the Drug Abatement Division experiences a high number of inspection cancellations. This is partly because its inspection scheduling decisions are based on inaccurate or incomplete company data and it does not coordinate with FAA Flight Standards inspectors to share information prior to scheduling inspections. When these cancellations occur, FAA has not established a risk-based process for selecting substitute companies for inspection. As a result, the Agency is missing opportunities to better target its drug and alcohol program inspections based upon available data and those companies that pose greater risks.Our RecommendationsWe made two recommendations to improve the effectiveness of the Drug Abatement Program. FAA concurred with both of our recommendations. We consider both of our recommendations resolved but open pending completion of planned actions.

The Refugee Act of 1980 created the Refugee Resettlement Program (RRP) to provide for the effective resettlement of refugees and to assist them in achieving economic self-sufficiency after arriving in the United States. The Act provides Federal grants to States for cash and medical assistance, social services, and targeted assistance to help qualified refugees. Within HHS, the Administration for Children and Families, Office of Refugee Resettlement (ORR) runs the RRP program. In 2015 and 2016, ORR obligated $286 million and $417 million, respectively, to States for the RRP.