Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Caribbean Healthcare System, which includes the San Juan VA Medical Center in Puerto Rico and multiple outpatient clinics in Puerto Rico and the U.S. Virgin Islands. The inspection covers key processes associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.When the team conducted this inspection, the healthcare system’s leaders had worked together in their positions for less than one month. However, they had worked together in other capacities for over two years. Employee survey results highlighted opportunities to improve staff feelings of moral distress. Patient experience survey results identified opportunities for improvement in specialty care settings. Review of the facility’s accreditation findings, sentinel events, and disclosures identified concerns with the system’s completion of institutional disclosures as well as the actions taken following serious adverse events. The executive leaders spoke knowledgeably within their scope of responsibilities about VHA data and factors contributing to poorly performing quality and efficiency measures.The OIG issued 10 recommendations for improvement in five areas:(1) Leadership and Organizational Risks• Institutional disclosures• Root cause analyses(2) Quality, Safety, and Value• Surgical work group meeting attendance(3) Registered Nurse Credentialing• Primary source verification(4) Care Coordination• Active medication list transmission• Nurse-to-nurse communication(5) High-Risk Processes• Disruptive behavior committee meeting attendance• Patient notification of Orders of Behavioral Restriction• Workplace Behavioral Risk Assessment• Staff training

We conducted a performance audit of two National Endowment for the Arts (NEA) Partnership awards issued to the Florida Department of State, Division of Cultural Affairs (Division). Based on our review, we determined the Division generally met the financial and compliance requirements in the award documents. However, we determined the following areas require improvement. The Division: overstated $34,339 in costs on the 2017 award’s Federal Financial Report (FFR) and understated $453,574 in costs on the 2018 award’s FFR; did not establish documented procedures for determining the Federal allowability of costs reported on its FFRs; did not notify all subrecipients of Federal subaward management requirements; and did not verify all potential vendors or subrecipients were eligible to participate in Federal programs and activities.We believe the evidence obtained during the audit provides a reasonable basis for our findings and conclusions based on our audit objectives. We questioned $34,339 in overstated costs on the 2017 award’s FFR. There are five recommendations to address the audit findings -- four to the Division and one to the NEA.

An audit to assess the Commission's implementation of its privacy program in accordance with federal law (42 USC Sec. 2000ee-2), regulation, and policy. Specifically, the audit was to determine whether the Commission implemented comprehensive privacy and data protection policies and procedures governing the Commission's collection, use, sharing, disclosure, transfer, storage and security of information in an identifiable form relating to Commission employees and the public.