Federal Reports

The Agency needs to improve oversight of its approximately $25 million in annual purchase card and convenience check expenses to be better stewards of taxpayer dollars.

Our objective was to determine whether fiscal year (FY) 2020 expenditures of the Postal Service Board of Governors (Board) were properly supported, reasonable, and complied with Postal Service and Board policies and procedures.The Postal Reorganization Act of 1970, as amended, established the Board which is comprised of nine governors appointed by the president of the United States, the postmaster general, and the deputy postmaster general. While the members of the Board changed through the year, as of September 30, 2020, the Board consisted of the chairman, five governors, and the postmaster general.

The VA Office of Inspector General (OIG) conducted an inspection to assess the oversight and performance of a physician in fellowship training (subject physician) at the VA Sierra Nevada Health Care System in Reno (facility).In early 2021, Canadian authorities arrested the subject physician for the alleged murder of a patient. The subject physician participated in a University of Nevada, Reno (UNR) affiliated geriatric fellowship from fall 2018 through fall 2019, providing care to patients at the facility. The OIG initiated an inspection to review the subject physician’s patient care, the facility’s oversight of the subject physician, and assess VA leaders’ response to the reported allegations.The OIG identified 105 patients that the subject physician provided care to, 17 of whom died. The OIG reviewed the 17 deaths, finding no deficiencies in the quality of care provided by the subject physician, and no patients died from events outside the naturally expected clinical course. The OIG noted an acceptable level of patient care management by the subject physician and found no statistically significant relationship between the subject physician’s rotations and patient deaths.The facility staff and leaders, in conjunction with UNR, onboarded the subject physician per Veterans Health Administration (VHA) requirements. The subject physician’s supervision and evaluation during the fellowship met performance standards and VHA requirements.The OIG determined that facility leaders initiated an issue brief and conducted an electronic health record review of the patients the subject physician treated. However, the Veterans Integrated Service Network (VISN)-led review only included two patient deaths. Based on the criminal allegations, the OIG requested a review focused on the subject physician’s care provided prior to relevant patients’ deaths. The VISN completed the review of an additional seven patients, noting no clinical deficits in care or contribution to patient deaths.The OIG made no recommendations.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of Veterans Health Administration facilities’ reusable medical equipment (RME) programs. This evaluation focused on facility Sterile Processing Services (SPS) processes for reusable medical equipment related to administration, quality assurance, and staff training.This report describes RME-related findings from healthcare inspections performed at 36 Veterans Health Administration medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with key staff and reviews of clinical and administrative processes. The OIG reviewers examined relevant documents and training records, observed reprocessing and storage areas, and interviewed key managers and staff. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses in various key RME-related processes and issued seven recommendations related to:• Standard operating procedures aligning with manufacturers’ guidelines• Annual risk analysis reporting to the VISN SPS Management Board• SPS chiefs developing, implementing, and enforcing a daily cleaning schedule for all SPS areas• Equipment storage• Completion of Level 1 training within 90 days of hire, competency assessments for RME, and monthly continuing education for SPS staff

We have performed audits in multiple States in response to a congressional request concerning deaths and abuse of residents with developmental disabilities in group homes. Federal waivers permit States to furnish an array of home and community-based services to Medicaid beneficiaries with developmental disabilities so that they may live in community settings and avoid institutionalization. The Centers for Medicare & Medicaid Services (CMS) requires States to implement a critical incident reporting system to protect the health and welfare of Medicaid beneficiaries receiving waiver services.