Federal Reports

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the West Texas VA Health Care System. The inspection covers 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; 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 leadership team was relatively new, having worked together for four months as of the week of the OIG’s visit. Selected survey scores related to employee satisfaction and patient experiences demonstrated various opportunities for improvement. Review of the facility’s accreditation findings, sentinel events, disclosures, and safety indicators did not identify any substantial organizational risk factors. The leadership team should continue to take actions to sustain and improve performance measures contributing to the Strategic Analytics for Improvement and Learning and community living center “1-star” quality ratings. OIG issued 13 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Completion of required number of root case analyses • Patient safety annual report review • Resuscitative episode reviews (2) Controlled Substances Inspections • Monthly summary of findings and quarterly trends reports to the director • Quarterly quality management review of reports • Annual competency assessments • Verification of orders (3) Military Sexual Trauma Follow-up • Staff training (4) Geriatric Care: Antidepressant Use among Elderly • Patient/caregiver medication education (5) Women’s Health • Women Veterans Health Committee core membership (6) Emergency Department and Urgent Care Center Operations • Stop code for identification of Urgent Care Center patients • Contingency plan and back up call schedule • Emergency department integration software use

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 17: VA Heart of Texas Health Care Network, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following Texas VISN 17 facilities were also performed: El Paso VA Health Care System (HCS); VA Texas Valley Coastal Bend HCS, Harlingen; and West Texas VA HCS, Big Spring. The VISN 17 leaders had worked together for over two years. Selected survey scores related to employee satisfaction and attitudes toward the workplace were generally above VHA averages, except for the Chief Medical Officer who appears to have opportunities for improvement. The leaders appeared to support efforts to improve patient safety, quality care, and other positive outcomes; however, patient experience results identified various improvement opportunities for the VISN to support its facilities. Review of VISN access metrics and clinician vacancies did not identify any significant organizational risks. The leaders were knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics, but should continue to support facility actions to improve care provided throughout VISN 17. The OIG issued seven recommendations for improvement: (1) Quality, Safety, and Value • Quality, safety, and value committee meets quarterly; and analyzes and reviews aggregated data • Peer review data collected and analyzed (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • VISN safety and network emergency management committee processes (4) Controlled Substances Inspections • Quarterly trend report reviews

The Child Care and Development Block Grant Act (CCDBG Act) of 2014 added new requirements for States that received funding from the Child Care and Development Fund (CCDF) to conduct comprehensive criminal background checks on staff members and prospective staff members of childcare providers every 5 years. Criminal background check requirements apply to any staff member who is employed by a childcare provider for compensation or whose activities involve the care or supervision of children or unsupervised access to children.

What Office of Inspector General Evaluated

The objectives of this audit were to: 

• Determine whether Financial Service Directorates estimate of lost early pay discounts on accounts payable invoices was accurate
• Identify fiscal year contracts that the Library awarded to vendors on the General Services Administration’s schedules that included discount terms for early payment to determine whether the Library captured the discounts on contracts affiliated with the schedules

What Office of Inspector General Found

• The Library is failing to include early payment discounts into contracts awarded under GSA schedules, and did not take advantage of discounts that vendors were required to offer.
• The Library is not taking advantage of all early payment discounts offered by vendors.

What Office of Inspector General Recommend

• Incorporate early payment discount terms, offered by vendors in General Services Administration schedules, into Library contracts so that the Library has the Opportunity to earn the discounts offered.
• To the extent it is legally and administratively possible, pursue collections for invoices paid both prior to and after February 24, 2019, for the 38 Library contracts awarded from GSA contracts containing early payment discount terms. In addition, the Library should also earn, and receive all discounts on invoices submitted for these contracts subsequent to our Audit report.   
• Instruct  Contracting Officers’ Representatives to notify Financial Services Directorate of any early payment discount terms offered by a vendor on an invoice, which are not included in the invoice processing platform drop down menu. Financial Services Directorate should then update the drop down menu to include the applicable discount terms, to ensure that the vendor can select the appropriate early payment discount terms from the drop down menu on future invoices.
• Instruct the Contracting Officers’ Representatives to review the actual invoice submitted by the vendor for early payment discount terms being offered.
• Instruct the Contracting Officers’ Representatives to review the comment section in invoice processing platform for each invoice, and Identify fiscal year any early payment discount terms offered by the vendor.