Federal Reports

Texas did not fully comply with Federal Medicaid requirements for billing manufacturers for some rebates for pharmacy drugs dispensed to managed-care organization enrollees. Texas properly processed claims for rebates in most instances; however, some claims were bypassed in the Drug Rebate Analysis and Management System and were not processed for rebate. The bypassed claims occurred during the rebate billing for the second quarters of 2012 and 2014. These claims were bypassed because they were loaded during the rebate invoicing process and Texas did not perform the required invoice recalculation to ensure they were applied to the current quarter. The bypassed claims resulted in 220,336 claim lines that were not invoiced for rebate. The rebates associated with these claims total $7.8 million ($4.4 million Federal share).

Our transmittal begins on page 51 of the Defense Logistics Agency General Fund Fiscal Year 2017 Agency Financial Report.

Our transmittal begins on page 45 of the Defense Logistics Agency Transaction Fund Fiscal Year 2017 Agency Financial Report.

Our transmittal begins on page 65 of the Defense Logistics Agency Working Capital Fund Agency Financial Report for Fiscal Year 2017.

This evaluation focused on the appropriateness of programming, training, and evaluation; the adequacy of Volunteer support; and the effectiveness of post leadership and management. While there are many areas of strength for this post, there are 22 recommendations. The majority are directed at the areas of programming, site development, and training.

Our objective was to quickly alert FEMA and its partners about attempts to profit from hurricane survivors seeking disaster assistance in Puerto Rico. FEMA must quickly take steps to stop those attempting to profit from survivors seeking disaster assistance through a fee for service that FEMA provides at no cost to the disaster survivor. The service advertised to complete required FEMA forms in order to obtain disaster assistance will require disaster survivors to provide a third party with their Personally Identifiable Information that will expose them to unnecessary risks. This management alert did not contain any recommendations

In response to concerns raised by immigrant rights groups and complaints to the Office of Inspector General (OIG) Hotline about conditions for detainees held in U.S. Immigration and Customs Enforcement (ICE) custody, we conducted unannounced inspections of five detention facilities to evaluate their compliance with ICE detention standards. We identified problems that undermine the protection of detainees’ rights, their humane treatment, and the provision of a safe and healthy environment. Although the climate and detention conditions varied among the facilities and not every problem was present at all of them, our observations, interviews with detainees and staff, and our review of documents revealed several issues. Upon entering some facilities, detainees were housed incorrectly based on their criminal history. Further, in violation of standards, all detainees entering one facility were strip searched. Available language services were not always used to facilitate communication with detainees. Some facility staff reportedly deterred detainees from filing grievances and did not thoroughly document resolution of grievances. Staff did not always treat detainees respectfully and professionally, and some facilities may have misused segregation. Finally, we observed potentially unsafe and unhealthy detention conditions.

Management and Performance Challenges Facing the Railroad Retirement Board

Our objective was to evaluate inbound international mail acceptance at U.S. Postal Service International Exchange Offices (IEOs). Inbound international mail originates in foreign countries for delivery in the U.S. and typically arrives at one of the five Postal Service International Service Centers (ISC) located in Chicago, IL; Los Angeles, CA; Miami, FL; New York, NY, and San Francisco, CA. Postal Service policy also lists 22 IEOs that accept international mail.

We found that FSA established policies and procedures related to the intake and discharge of borrower defense claims in 2015 and refined the claims intake policies and procedures throughout our review period. FSA also established policies and procedures related to reviewing borrower defense claims in April 2016 and introduced new policies and procedures throughout our review period. However, we identified weaknesses with FSA’s procedures for: (1) documenting the review and approval of legal memoranda establishing categories of borrower defense claims that qualified for discharge, (2) reviewing borrower defense claims, (3) processing claims approved for loan discharge and flagged for denial, and (4) establishing timeframes for claims intake, claims review, loan discharge, and claims denial processes and controls to ensure timeframes are met.

During our August 2017 site visit to the FLETC Artesia Training Center, we identified a potential safety issue at a warehouse, Building 13. The Border Patrol Academy had been using the warehouse to train new hires on search and conveyance. In 2009, a vehicle from an adjacent driving course struck the warehouse. FLETC officials could not provide documentation to support that an engineering evaluation was conducted to determine whether the accident affected the integrity of the warehouse structure. Border Patrol Academy officials also expressed safety concerns about using the warehouse to train new hires.

During our August 2017 site visit to the FLETC Artesia Training Center, we identified a potential safety issue at a warehouse, Building 13. The Border Patrol Academy had been using the warehouse to train new hires on search and conveyance. In 2009, a vehicle from an adjacent driving course struck the warehouse. FLETC officials could not provide documentation to support that an engineering evaluation was conducted to determine whether the accident affected the integrity of the warehouse structure. Border Patrol Academy officials also expressed safety concerns about using the warehouse to train new hires.

In accordance with FY 2017 IG FISMA Reporting Metrics, the objective of the evaluationwas to determine the effectiveness of the information security program and practices of theCommission. The scope of this evaluation focused on the Commission’s General SupportSystem (GSS) and related information security policies, procedures, standards, andguidelines.

We determined whether the Joint Attack Munition Systems (JAMS) project office adequately assessed the affordability of the Joint Air-to-Ground Missile (JAGM) increment one.

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Bath VA Medical Center (facility). This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 29 employees.The facility has generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. OIG noted findings in five of the six areas of clinical operations reviewed and issued 11 recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Credentialing and privileging data reviews• Utilization management documentation(2) Medication Management: Anticoagulation Therapy• Provision of medication education to patients(3) Environment of Care• Environment of care rounds frequency and attendance• Maintenance of required number of filled oxygen tanks and an adequate supply of personal protective equipment• Storage of clean and sterile supplies(4) Mental Health Residential Rehabilitation Treatment Program• Monthly self-inspections, weekly contraband inspections, every 2-hour rounds of public spaces, and daily resident room inspections• Security at entrance doors

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Eastern Kansas Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 118 employees.The facility had generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the facility through active stakeholder engagement). OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and SAIL results did not identify any substantial organizational risk factors.OIG noted findings in four of the six areas of clinical operations reviewed and issued five recommendations that are attributable to the Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value• Review of Ongoing Professional Practice Evaluation data• Documentation of decisions by Physician Utilization Management Advisors(2) Medication Management: Anticoagulation Therapy• Education for patients with newly prescribed anticoagulant medications(3) Environment of Care• Locked Mental Health Unit Interdisciplinary Safety Inspection Team training(4) Long-Term Care: Community Nursing Home Oversight• Cyclical clinical visits

The U.S. Department of health and Human Services (HHS) oversees States' administration of various Federal programs, including Medicaid. State agencies are required to establish appropriate computer system security requirements and conduct biennial reviews of computer system security used in the administration of State plans for Medicaid and other Federal entitlement benefits. This review is one of a number of HHS OIG reviews of States' computer systems used to administer HHS-funded programs.

We conducted a series of OIG audits at four HHS Operating Divisions (OPDIVs) using network and web application penetration testing to determine how well HHS systems were protected when subject to cyberattacks.

Statement of the Honorable Eric M. Thorson, Inspector General, Department of the Treasury, Office of Inspector General, provided to the House Financial Services Committee Subcommittee on Oversight and Investigations for the hearing on "Examining the Office of Financial Research", December 7, 2017 10am. (Written Testimony)

Inspectors General have found significant weaknesses affecting Federal programs serving American Indian and Alaska Native (AI/AN) communities. This report compiles information from recent Office of Inspector General (OIG) audits, evaluations, and investigations to identify vulnerabilities and breakdowns that cut across departments. CIGIE chose this area for study given the level of Federal funding and number of agencies involved, as well as the Federal Government’s special obligation to protect AI/AN interests and fund vital services. Throughout the report, we highlight examples of past OIG findings and recommendations to illustrate these common themes.

The Tennessee Valley Authority's (TVA) Interruptible Power (IP) program implemented new products in October 2015 as part of the product redesign of TVA's demand response portfolio. We initiated this audit in response to concerns forwarded to our office regarding (1) the amount of credits provided through TVA's interruptible products and (2) whether or not these products were a cost effective way for TVA to obtain power. Our audit objective was to determine if the monetary value obtained by TVA during fiscal years 2016 and 2017 was more than the cost of providing these interruptible pricing products to customers. Our audit included interruptible product credits issued and other financial data related to interruption events for participating commercial and industrial customers from October 1, 2015, through March 31, 2017, which totaled $78.5 million. In summary, we found the monetary value obtained by TVA during fiscal years 2016 and 2017 was more than the cost of providing the interruptible pricing products introduced in October 2015 to participating commercial and industrial customers. However, we also found documentation related to the interruptible valuation is not maintained in a central location. We recommended TVA's Vice President, Pricing and Contracts, maintain all supporting documentation related to the annual interruptible valuation in a central location. TVA management agreed with the audit findings and recommendation in this report and plans to take corrective action.(Summary Only)

OIG evaluated whether the Veterans Health Administration (VHA) effectively managed providers’ primary care panels to maximize access to primary care providers by evaluating new enrollee processing into panels as well as the panel sizes. Provider panels define both VHA’s capacity to provide managed outpatient care and provider efficiency based on the number of veterans managed for primary care.In the first seven months of FY 2015, VHA had not effectively managed provider panels to maximize access. VHA facilities’ methods for processing and scheduling veterans into panels varied, and veterans encountered an average wait of 29 days from the date they enrolled until the facility scheduled their appointment. The average of 29 days was not included in VHA’s wait time calculation. VHA facilities had panels below VHA’s panel size recommendations with six of the seven facilities showing panels 13 to 30 percent below the model. This occurred because VHA lacked standard procedures for processing new enrollees, did not track the wait-time from the enrollment to scheduling, and did not ensure compliance with recommended panel sizes. As a result, VHA’s recorded wait times did not accurately reflect the wait experienced. VHA’s recorded wait time showed about 8 percent of newly enrolled veterans waited more than 30 days when OIG determined about 53 percent of newly enrolled veterans completed their first appointment more than 30 days past the determined eligibility date.Lower panel sizes equated to almost $169 million in underutilized provider salaries paid in fiscal year 2015. OIG recommended the Acting Under Secretary for Health establish standardized new enrollee scheduling procedures that properly track wait times and ensure facilities either set panel sizes at VHA’s model goals or justify deviations. The Acting Under Secretary for Health concurred with the recommendations and OIG will monitor VHA’s progress until all proposed actions are completed.

This report contains Sensitive But Unclassified information. To obtain further information, please contact the OIG Office of Counsel at OIGCounsel@oig.treas.gov, (202) 927-0650, or by mail at Office of Treasury Inspector General, 1500 Pennsylvania Avenue, Washington DC 20220.

OIG has conducted numerous audits, evaluations, and investigative work involving personal care services (PCS) and offered recommendations for improving program oversight. Medicaid Fraud Control Units (MFCUs or Units) investigate and prosecute Medicaid provider fraud and patient abuse or neglect under State law. We conducted this study to provide data on MFCU investigations, indictments, and convictions involving fraud and patient abuse in Medicaid PCS.

The objective of our evaluation was to determine whether all Military Services Law Enforcement Organizations (LEOs) had submitted fingerprint cards and final disposition reports for Military Service members convicted by court-martial of qualifying offenses, as required by DoD instruction. We reviewed these submissions for the period from January 1, 2015, to December 31, 2016.

OIG received an anonymous allegation that Veterans Service Center (VSC) staff at the Roanoke VA Regional Office (VARO) combined appeals to lower the pending inventory and achieve production goals by entering incorrect data into VA’s electronic system. OIG reviewed 331 appeal records that were closed indicating they were withdrawn by appellants. OIG determined 278 were improperly closed because the electronic record did not contain any evidence of a withdrawal request by the appellant. In 276 of the 278 closed appeal records, the pending issues were merged with other open appeal records. In two cases, appeals management and staff failed to add all pending issues to other open appeal records. Both of these appeal records were reactivated as a result of OIG’s review. Merging issues into one record was a longstanding practice at the Roanoke VARO to reduce the pending workload. VARO and VSC management were unaware of this practice, and appeals managers knew of it but were unaware of its full impact. Merging appeal records gave a false impression that the appeals inventory decreased. Subsequently, the reported statistics for the number of pending and completed appeals at the Roanoke VARO were inaccurate, and the associated timeliness measurements were unreliable. OIG could not determine what the VARO’s actual statistics should have been since staff appeared to have been following this guidance from at least September 2008. OIG recommended the Roanoke VARO Director conduct a review to identify prematurely closed appeal records and confer with appropriate Veterans Benefits Administration officials to determine the proper corrective actions to take, if any. OIG also recommended the Director confer with regional counsel to determine what steps to take, if any, with regard to management or staff involved in the conduct discussed in this report. The VARO Director concurred with our recommendations and planned corrective actions are responsive.

Transportation Security Administration (TSA) intended to expand TSA PreCheck to 25 million air travelers at a rate of more than 5 million enrollments per year. We evaluated whether the current TSA PreCheck Application Program adjudication process will allow TSA to meet its enrollment goals. TSA did not allocate additional resources or staff to the TSA Adjudication Center, which had multiple vacancies and was tasked with manually processing about 26 percent of TSA PreCheck Application Program applications. To make matters worse, in June 2016, TSA PreCheck applications surged, leaving the Adjudication Center overwhelmed with applications to process. As the application queue grew, TSA brought on detailees from other Federal agencies to assist with adjudications part time, but they did not have a significant impact. Further, the Adjudication Center relies on a manual caseload assignment and reporting process, which is inefficient for the volume of TSA PreCheck applications needing adjudication.

We determined that Osceola generally complied with Federal regulations and FEMA guidelines in accounting for and expending Federal (FEMA) grant funds. However, Osceola’s procurement procedures were not adequate to meet minimum Federal standards and to address the key procurement element of ensuring no award is made to any party debarred or suspended from Federal assistance programs. Despite this, we are not questioning costs because no contracts were awarded to debarred or suspended contractors and Osceola took corrective measures to include contractor verification in all future awards for disaster-related projects. The report contains no recommendations and we did not identify issues requiring further action from FEMA. Therefore, we consider this audit closed.

We determined that the County has in place policies, procedures, and business practices to generally account for and expend FEMA Public Assistance grant funds according to Federal regulations and FEMA guidelines. The County can account for disaster-related costs on a project-by-project basis and adequately support these costs. In addition, the County’s procurement policies, procedures, and practices are consistent with Federal procurement standards. Therefore, if the County follows those policies, procedures, and business practices; FEMA has reasonable, but not absolute, assurance that the County will properly manage the FEMA Public Assistance grant funds according to Federal regulations. Because the audit did not identify any reportable issues, we are not requiring any further action from FEMA.

This is a Department of Homeland Security Office of the Inspector General (OIG) special report on Federal Emergency Management Agency (FEMA) and FEMA recipient and sub recipient disaster-related procurements. FEMA is currently responding to some of the most catastrophic disasters in U.S. history — Hurricanes Harvey, Irma, Maria, and the October 2017, California wildfires. Because of the massive scale of damage and the large number and high-dollar contracts that will likely be awarded, there is a significant risk that billions of taxpayer dollars may be exposed to waste, fraud, and abuse.

We determined that U.S. Immigration and Customs Enforcement (ICE) properly awarded the FCMP contracts and in most cases complied with applicable laws, regulations, and guidance during the acquisition process. Specifically, ICE promoted fair and open vendor competition during the family case management services solicitation process by publicly issuing notices and requests for proposals. In addition, ICE evaluated vendor proposals in accordance with established criteria and selected the vendor based on a comparative evaluation of proposals, which were adequately documented in the contract file. The report contained no recommendations.

His House Children's Home, Inc. (His House), an Unaccompanied Alien Children (UAC) grantee responsible for caring for children in Office of Refugee Resettlement (ORR) custody, met safety standards for the care and release of children in its custody. However, some UAC case files were missing evidence of sponsor background checks and other required documentation. His House claimed only allowable expenditures. However, we identified areas in which His House lacked an efficient and effective system of internal controls when administering UAC program funds.

Pine Bluff Jefferson County Economic Opportunities Commission (Pine Bluff) did not always claim Head Start grant costs that were allowable and allocable in accordance with Federal regulations. Specifically, Pine Bluff claimed $392,094 of unsupported non-Federal share; $214,372 in costs that did not meet procurement-related requirements; and $123,158 in costs that either did not benefit the Head Start program or may not have benefited the Head Start program.

An audit report required by the Accountability of Tax Dollars Act of 2002.

The report summarizes the FTC OIG’s activities and accomplishments during the second half of the FY 2017 reporting period.

During this reporting period, the DHS Office of Inspector General (OIG) completed significant audits, inspections, and investigations to promote economy, efficiency, effectiveness, and integrity in the Department’s programs and operations.We issued 72 reports, including management alerts, and reports on Disaster Relief Fund spending (appendix 5), as well as 367 investigative reports, while continuing to strengthen our transparency and internal oversight. Our reports provide the DHS Secretary and Congress with an objective assessment of the issues the Department faces. They also offer specific recommendations to correct deficiencies and improve the economy, efficiency, and effectiveness of DHS’ programs.

OIG conducted a healthcare inspection in response to an allegation received in 2016 that a patient died of an accidental methadone overdose 2 days after receiving a prescription for methadone from a primary care physician (PCP) at the Grand Junction VA Health Care System (System), Grand Junction, CO. We substantiated the allegation that the patient identified in the complaint died 2 days after receiving a prescription for methadone from a System PCP. We were unable to substantiate that methadone contributed to or was the cause of the patient’s death. Neither an autopsy or toxicology study was performed, so additional information was not available.The System lacked a process to ensure prescribers were aware of, or considered, current Veterans Health Administration (VHA) directives, policies, and guidance related to obtaining an electrocardiogram before prescribing methadone for the management of chronic pain. VHA’s “Consent for Long-Term Opioid Therapy for Pain” is an electronic document that is used to obtain consent for long-term opioid therapy. The template document may also be used as a patient education tool but does not include risk factors specific for methadone. System PCPs we interviewed were not aware of how to add methadone specific risk factors to the electronic consent form. After investigating the events surrounding the death of the patient identified in the complaint, System leaders did not confer with the Office of Chief Counsel to determine if an institutional disclosure was necessary. We made five recommendations.

We determined that the Office of Health Affairs (OHA) has not implemented an effective organizational framework for safeguarding personally identifiable information (PII). While OHA appointed a Privacy Officer, this official lacked authority and resources to carry out the required privacy management responsibilities. Given turnover in key positions, OHA leadership had not placed priority on instilling a culture of privacy which resulted in transparency and security control weaknesses. For example, OHA’s emergency medical first responders did not properly notify individuals of their privacy rights when collecting PII. OHA’s BioWatch web portal had been improperly categorized to properly safeguard PII and the portal operated on an untrusted internet site. We recommended that OHA inform its staff of the Privacy Officer’s statutory responsibilities and the need for all staff to comply with privacy requirements, implement a process to provide a Privacy Act Statement when collecting PII from individuals as required by law, and move the BioWatch web portal to a trusted domain to comply with system security requirements and to safeguard PII. We made eleven recommendations improve privacy stewardship and reduce privacy risks to PII that OHA collects and maintains.

As FEMA moves into the recovery phase for Hurricane Harvey in Texas, it will begin to obligate millions, if not billions, of dollars from the Disaster Relief Fund for administrative costs and for Public Assistance and Hazard Mitigation grants to eligible State, tribal, and local governments and certain nonprofit organizations. Texas, as a FEMA grant recipient, will be responsible for oversight and monitoring of the disaster grants to Texas subrecipients. Our prior reports identified FEMA faced resource challenges in its response to a May 2015 Texas flooding disaster and determined that Texas needs to improve its grant management efforts. We urge FEMA officials to be mindful of lessons learned from these prior reports in providing disaster assistance to Hurricane Harvey survivors and that they closely monitor Texas’ grant management activities. Doing so should provide reasonable, but not absolute, assurance that Federal disaster assistance funds are spent properly and that the risk of ineligible and excessive costs borne by taxpayers is mitigated.

We determined that the U.S. Citizenship and Immigration Services’ (USCIS) automation of the N-400 Application for Naturalization has not been successful. Specifically, we found that ELIS did not have the critical functionality necessary for end-to-end N-400 processing. The problems in N-400 automation can be attributed to poor program management practices, which have continued since prior ELIS releases. We made 5 recommendations for USCIS to address its training needs, perform a risk-based analysis of all unresolved ELIS technical issues, implement a plan for reducing ELIS technical debt, clearly define agency-wide business goals and objectives, and implement a plan to ensure that ELIS provides USCIS personnel with complete, timely, and accurate data to enable more effective benefits adjudication decisions. USCIS concurred with all 5 of our recommendations.

We determined that DHS did not always follow statutory requirements when entering, modifying, and overseeing its agreements. Inadequate internal policies contributed to DHS falling short of meeting all statutory requirements for using Other Transaction Authorities (OTA). In addition, DHS staff within the office responsible for DHS’ acquisition policy explained that competing priorities prevented timely reporting to Congress. As a result, DHS may have taken on more risks and costs than would otherwise be necessary, as well as impeded on Congress’ ability to oversee its use of OTAs. We recommended that DHS modify its policies regarding these matters and correctly report to Congress. We made three recommendations and DHS concurred with all of our recommendations.

The Omaha Tribe’s serious financial management weaknesses combined with inadequate and missing documentation resulted in unreliable financial records. As a result, we have little confidence that the transactions recorded in the accounting system actually occurred or that the tribe completed its FEMA-authorized projects. Therefore, we question $13.9 million as unsupported. Due to the unreliable financial information, we calculated the amount unsupported as the entire $16.9 million FEMA provided for both grants, less $2.8 million in unused Federal funding that FEMA should put to better use; $165,000 in unclaimed insurance coverage; and approximately $74,749 that we were able to verify as supported and eligible.

The Missouri Department of Social Services (State agency) did not always comply with Federal and State requirements when making payments under its Child Care subsidy program for State fiscal years 2014 and 2015. Client attendance records were not adequately documented for 124 of the 128 provider service months in our statistical sample; childcare payments made for claims in those 124 provider service months were therefore unallowable. (A provider service month includes all childcare payments paid to a childcare provider for a single month of service.)

The Office of Inspector General is tasked with ensuring efficiency, accountability, and integrity in the U.S. Postal Service. We also have the distinct mission of helping to maintain confidence in the mail and postal system, as well as to improve the Postal Service's bottom line. We use audits and investigations to help protect the integrity of the Postal Service. Our Semiannual Report to Congress presents a snapshot of the work we did to fulfill our mission for the six-month period ending Spetember 30, 2017.

This semiannual report informs Congress of the Peace Corps Office of Inspector General's work for April 1, 2017 through September 30, 2017.

Our objective was to evaluate the throughput and productivity performance of the U.S. Postal Service’s 33 deployed Small Package Sorting System (SPSS) machines. We found that on average nationally, the SPSS machine throughput performance goal was exceeded by about five percent from January 1, 2016, through July 31, 2017. We also found that on average nationally, the Postal Service was not meeting its SPSS productivity goal by about 17 percent from January 1, 2016, through July 31, 2017.

Results of the audit of the Commission’s financial statements for the fiscal year ended September 30, 2017

Report Summary: The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Long Beach Healthcare System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 151 employees.The facility has generally stable executive leadership to support patient safety and quality care. However, the presence of multiple organizational risk factors, such as adverse event disclosures, reported in-hospital complications, and adverse events following surgeries and procedures, may contribute to future issues of lapses in patient safety unless corrective processes are implemented and continuously monitored. Facility leaders should continue to take actions to improve performance of selected Strategic Analytics for Improvement and Learning metrics, particularly Quality of Care metrics.OIG noted findings in five areas of clinical operations reviewed and issued 14 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Review of Ongoing Professional Practice Evaluation data(2) Medication Management: Anticoagulation Therapy• Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers• Documentation of informed consent and patient stability for transfer• Resident supervision• Communication with accepting facility(4) Environment of Care• General safety and cleanliness• Infection prevention risk assessment• Dirty and used equipment storage• Panic alarm and security surveillance television system testing (5) Long-Term Care: Community Nursing Home Oversight• Oversight committee membership • Program integration• Cyclical clinical visits

The VA OIG conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the James J. Peters VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; and High-Risk Processes: Moderate Sedation. OIG also provided crime awareness briefings to 162 employees. The facility had generally stable executive leadership and active engagement with employees and patients to maintain high satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. OIG noted findings in the 5 areas of clinical operations reviewed and issued 15 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Frequency of Quality Executive Board meetings• Review of credentialing and privileging data• Utilization management reviews and documentation(2) Medication Management: Anticoagulation Therapy• Use of quality assurance data (3) Coordination of Care: Inter-Facility Transfers• Transfer data reporting and analysis• Documentation for acute patient transfers to other facilities(4) Environment of Care• Environment of Care rounds attendance• Panic alarm and security surveillance television system testing• Interdisciplinary Safety Inspection Team training(5) High-Risk Processes: Moderate Sedation• Monitoring of moderate sedation outcome data• Performance of history and physical examinations and pre-sedation assessments• Clinical staff training

To see our report, click on the link below