Federal Reports

We did not substantiate the allegations that an oil and gas company submitted false mineral production reports to ONRR.

Because the EPA did not disconnect unneeded GSA services in a timely manner, the Agency paid at least $7,850 for services it was not using.

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 Cheyenne VA medical center. The inspection covered key clinical and administrative processes that are associated with promoting quality care. This inspection focused on 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 OIG conducted this inspection, the medical center’s leaders had worked as a team for approximately 14 months. Employee satisfaction survey results indicated that the Associate Director had opportunities to model servant leadership and improve staff’s perception of workplace respect and their ability to discuss concerns. The Associate Director for Patient Care Services had an opportunity to reduce staff’s feelings of moral distress. Patient experience survey results showed general satisfaction with the care provided.The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the Chief of Staff and Associate Director for Patient Care Services had opportunities to improve their understanding of selected Strategic Analytics for Improvement and Learning data, and all leaders should continue actions to improve and sustain quality and efficiency.The OIG issued seven recommendations for improvement in three areas:(1) Quality, Safety, and Value• Surgical work group meeting attendance(2) Care Coordination• Patient transfer monitoring and evaluation• Transfer form completion• Medical record transmission(3) High-Risk Processes• Disruptive behavior reporting and tracking• Disruptive Behavior Reporting System• Staff training

The VA OIG assessed the Southeast Louisiana Veterans Health Care System’s oversight and stewardship of funds for fiscal year 2019 and identified opportunities to improve cost efficiency.The review focused on four areas:I. Use of the Medical/Surgical Prime Vendor Next Generation program. VA maintains contracts with vendors to streamline medical supply purchasing and distribution. Because its prime vendor did not fill orders consistently, the system bought only about 75 percent of its supplies through the program, falling short of VA’s recommended 90 percent goal. The system also did not always monitor the prime vendor’s performance or report performance problems to VA.II. Purchase card use. The team sampled 102 purchase card transactions and determined the system could instead have pursued contracts for 19 of them. Quarterly internal audits were also not completed on time, and approving officials did not adequately monitor cardholder purchases. In addition, the team identified 16 purchases that were split into smaller transactions to circumvent purchase limits, resulting in improper payments of about $140,016.III. Administrative staffing levels and accuracy of labor costs. The system used 251.6 more administrative full-time equivalents than other systems of similar size and complexity. The system’s director said this was partly due to initial staffing costs associated with a new medical center. The system has, however, implemented strategies to improve staffing efficiency and management.IV. Pharmacy operations and cost avoidance efforts. The system spent approximately $9 million more on prescription drugs than similar systems did. This was partly due to inaccurate or outdated prices in the system’s list of drugs and to low annual turnover of its drug supplies, but the system has made progress in improving efficiency and cost-saving efforts.The OIG made six recommendations to the healthcare system director to address the issues identified in this review.