Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Martinsburg VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value; Environment of Care (EOC); 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 OIG also provided crime awareness briefings to 67 employees. The Facility has generally stable executive leadership and active engagement with employees and patients. Organizational leaders support patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors; however, the Facility does not have a process established for the collection, tracking, and/or analysis of relevant information related to institutional disclosures. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the current 3-star rating. The OIG noted findings in four of the clinical operations reviewed and issued five recommendations that are attributable to the Facility Director, Acting Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Privilege-specific criteria developed and utilized for Focused Professional Practice Evaluations • Service-specific criteria developed and implemented for Ongoing Professional Practice Evaluations (2) EOC • Attendance during EOC rounds (3) Medication Management: CS Inspection Program • Appropriate verifications of CS orders (4) Women’s Health: Mammography Results and Follow-Up • Electronic linking of results to radiology order

The VA Office of Inspector General (OIG) conducted an inspection to evaluate allegations of inadequate staffing of intensivists (physicians who are specialists in the care of critically ill patients) and other Surgery Service concerns at the VA Gulf Coast Healthcare System (System), Biloxi, Mississippi. The OIG substantiated the System did not have full-time intensivist coverage during part of fiscal year 2017. However, the System had taken actions to mitigate patient risk during times that an intensivist was not available, including granting core critical care privileges for hospitalists (physicians who are specialists in the care of patients in the hospital) and diverting admissions for patients possibly needing intensive care unit (ICU) services. The System did not fully comply with risk-based surgical screening processes and selective scheduling of more complex surgeries. The System also did not fully comply with limiting surgeries to patients with pre-operative mortality risk calculations greater than 7.5 percent. The OIG did not find evidence of clinically significant adverse patient outcomes related to this non-compliance. The OIG did not substantiate that ICU patients died from complications as a result of inadequate [intensivist] staffing. Two ICU deaths occurred in late 2017 when an intensivist was not available. In both cases, the patients had metastatic (spread to distant sites) cancer and were subsequently placed on hospice or comfort measures only. The OIG substantiated that some of the intensivist staffing and Surgery Service-related conditions were not remedied after an external inspection. However, the System implemented an action plan to address identified concerns. The OIG also found examples of poor communication and responsiveness, and of improper documentation. The OIG recommended the Veterans Integrated Service Network Director provide oversight of ICU and Surgery Service-related operations until conditions are resolved, and the System Director follow through on incomplete actions and address improper health record documentation by two providers.

An OIG limited review revealed little Department policy or guidance in place regarding the unauthorized disclosure of Department documents to external sources, with the exception of the disclosure of personally identifiable information, proprietary information from companies, and security information.

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We completed a verification review of Recommendation 9, presented in our evaluation report, “Bureau of Land Management’s Renewable Energy Program: A Critical Point in Renewable Energy Development” (CR-EV-FWS-0004-2010), issued June 12, 2012. Our objective for this review was to determine whether the Bureau of Land Management implemented Recommendation 9 as reported to the Office of Financial Management, Office of Policy, Management and Budget. We concur that this recommendation has been resolved and implemented.

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The audit objectives were to determine whether (1) selected State educational agencies (SEA) were providing effective oversight of local educational agencies (LEA) and coordinating with other entities to implement selected Every Student Succeeds Act (ESSA) requirements related to identifying, educating, and reporting on homeless children and youths and (2) selected LEAs were effectively implementing selected ESSA requirements related to identifying, educating, coordinating services for, and reporting on homeless children and youths. Our audit covered the oversight and implementation of the selected ESSA requirements from October 1, 2016, through August 15, 2017. We determined that the New York SEA generally provided effective oversight of LEAs and coordinated with other entities to implement selected ESSA requirements related to identifying and educating homeless children and youths. However, we found that the New York SEA could improve its oversight of LEA data reporting and improve its internal controls by better documenting and updating policies and procedures, following up on LEA corrective actions from monitoring reviews, and providing technical assistance to LEAs related to the reporting of unaccompanied youths who are homeless. Based on the work we performed, we found that, generally, the LEAs were effectively implementing selected ESSA requirements related to coordinating services, identifying, educating, and reporting on homeless students. However, the LEAs could improve their internal controls by better documenting policies, procedures, and roles. Specifically, the New York City Department of Education's and the the Lackawanna City School District's homeless education policies were outdated and had not been revised to include the ESSA requirements. The Uniondale Union Free School District had not documented its data entry policies and procedures and the roles and responsibilities of officials responsible for informing parents or guardians of homeless students of the educational and related opportunities they are entitled to under the McKinney-Vento Act.