Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate a patient’s mental health care at the VA Portland Health Care System (facility) including care coordination, administrative actions following the patient’s death, and non-VA community care procedures. The OIG also evaluated VA Palo Alto Health Care System (VA Palo Alto) posttraumatic stress disorder residential rehabilitation treatment program (RRTP) processes.Facility staff made reasonable efforts to accommodate the patient’s treatment preferences, completed safety planning, and conducted required military sexual trauma screening and care. Facility leaders and staff did not assign a Mental Health Treatment Coordinator (MHTC) or establish a policy as required. Facility staff did not review the patient’s high risk for suicide patient record flag timely or ensure the facility’s High Risk Review Workgroup approved flag inactivation, inadequately managed the patient’s flag, and failed to assess suicide risk following the patient’s Veterans Crisis Line call.The OIG identified Veterans Health Administration (VHA) policy and suicide behavior reporting guidance inconsistencies and facility leaders did not follow VHA staff-specific guidance. Facility staff did not complete a behavioral health autopsy timely.VA Palo Alto RRTP staff did not complete the patient’s screening within VHA expectations and did not accept patient self-referrals. RRTP staff appropriately considered the patient’s service animal request. However, inconsistent with VHA policy, RRTP policy included additional admission requirements for the service animal.The OIG made two recommendations to the Under Secretary for Health related to suicide behavior and overdose report staff-specific guidance and RRTP admission decision timeframe expectations; three recommendations to the Facility Director related to MHTC policy and assignment, suicide behavior and overdose report staff-specific guidance, and behavioral health autopsy report timeliness; and two recommendations to the VA Palo Alto Director related to aligning facility RRTP procedures and assistance dog policies with VHA requirements.

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 Maine Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; 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.The leadership team appeared stable, with all the positions permanently assigned. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Patient experience survey results highlighted opportunities to improve female veterans’ satisfaction in inpatient and outpatient settings. The OIG’s review of the healthcare system’s accreditation findings, sentinel events, and disclosures of adverse patient events did not identify any substantial organizational risk factors. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to improve performance.The OIG issued eleven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Systems redesign and improvement program process• Peer review quarterly summaries• Surgical work group attendance(2) Care Coordination• Patient transfer policy• Patient transfer monitoring and evaluation• Informed consent• Transfer form completion• Nurse-to-nurse communication(3) High-Risk Processes• Disruptive behavior committee attendance• Disruptive Behavior Reporting System• Staff training

To enable veterans to function at their highest level, VA provides medically prescribed prosthetic and rehabilitative items and services to eligible recipients. In fiscal year 2019, such items—artificial limbs, shoes, shoe inserts, and compression garments—accounted for about $318.8 million, or about 9 percent of prosthetic spending.The Office of Inspector General (OIG) conducted this audit to determine if Veterans Health Administration (VHA) oversight ensured medical facilities paid reasonable prices when reimbursing vendors for prosthetic and orthotic items. Previous OIG audits identified weaknesses in VHA’s oversight, which led to overpayments to vendors and missed opportunities for cost savings.The OIG found VHA’s oversight of prosthetic spending was ineffective, resulting in medical facilities sometimes reimbursing vendors at unreasonable rates; medical facilities spent about $10 million more than reasonable rates in the six-month period from October 2019 through March 2020. Furthermore, the OIG found that prosthetic spending data was unreliable—about 36,200 transactions in the National Prosthetics Patient Database from October 2019 through March 2020 contained at least one inaccurate data element, including the price paid.Unreasonable rates, along with data inaccuracies, occurred because Prosthetic and Sensory Aids Service leaders did not assume their oversight role, assess laws and regulations applicable to prosthetic spending to ensure reasonable rates, review and update oversight roles and responsibilities in policies, or establish processes and procedures to monitor the accuracy of prosthetic spending data.The OIG made four recommendations, including determining and clarifying which reimbursement practices apply to the rates medical facilities pay vendors, monitoring spending to make sure medical facilities reimburse vendors at reasonable prices, establishing a formal oversight structure to define roles and responsibilities within the prosthetic program, and requiring routine monitoring of medical facilities’ data to improve accuracy.

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the Pennsylvania Bureau of Disability Determination (PA-BDD) for Fiscal Years (FY) 2017 and 2018; (2) determine whether the administrative costs claimed on the most recently submitted Form SSA-4513 were allowable and properly allocated; (3) reconcile funds drawn down with claimed costs; and (4) assess the general security controls environment.

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the Kentucky Disability Determination Services (KYDDS) for Fiscal Years (FY) 2017 and 2018; (2) determine whether the administrative costs claimed on the most recently submitted Form SSA-4513 were allowable and properly allocated; (3) reconcile funds drawn down with claimed costs; and (4) assess the general security controls environment.Note: 2 of 9 recommendations not published; related to sensitive IT matters.