Federal Reports

Without internal controls to track ETF program performance, the EPA risks underreporting environmental and human health outcomes.

Joseph Kieffer, a marketer from Los Angeles, was sentenced on September 8, 2021, in U.S. District Court, Central District of California, to six months in prison, three years’ probation, a $10,000 fine, and he was ordered to pay restitution in the amount of $1,250,000 and a money judgment of forfeiture of $328,835. Kieffer previously pleaded guilty to paying kickbacks to marketers and some patients to obtain medically unnecessary compounded drugs, which allowed Fusion RX Compounding Pharmacy to bill health care providers for those drugs. Many of the prescription claims were reimbursed at rates much higher than average medications. The owner of Fusion Rx Compounding Pharmacy was also charged for his role in the scheme. Amtrak’s health insurance plan was fraudulently billed $17,000 as a result. Criminal judicial proceedings for other defendants are pending.

Since 1991, veterans who served in the Republic of Vietnam are presumed to have been exposed to herbicides such as Agent Orange. The Blue Water Navy Vietnam Veterans Act of 2019 extended this presumption to include veterans who served within 12 nautical miles of Vietnam. The objective of this OIG review was to determine whether Veterans Benefit Administration (VBA) employees (1) notified Navy veterans of their potential eligibility to receive medical benefits under the act; (2) correctly determined the eligibility of the veterans who filed claims for benefits; and (3) made accurate decisions on claims. The OIG found that VBA met the outreach requirements outlined in the act. VBA employees also generally determined Blue Water Navy veterans’ eligibility for benefits correctly. However, VBA has not established procedures for its employees to follow when the computer search tool they use to determine ship locations during claimant service dates returns unlikely results (for example, providing an inland location in a search for an aircraft carrier). In addition, VBA employees inaccurately decided approximately 46 percent of veterans’ claims (2,100 of 4,600) from April through June 2020, which led to about $37.2 million in improper payments to veterans ($25.2 million in overpayments and $12 million in underpayments) during that period. About 95 percent of these errors resulted from VBA employees deviating from policies governing disability-rating decisions. The OIG made three recommendations to the under secretary for benefits: (1) establish procedures to follow when the ship locator tool provides unlikely results based on deck log coordinates, (2) ensure VBA employees understand how to accurately decide and evaluate herbicide-related medical conditions, and (3) begin periodic local reviews of rating decisions involving such medical conditions to mitigate error trends identified.

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 Eastern Oklahoma VA Health Care 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; 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.At the time of the OIG virtual review, all leadership positions were permanently filled. Survey data revealed opportunities to improve employee perceptions of leadership, reduce feelings of moral distress at work, and reduce fears of retaliation. Patient experience survey data highlighted a need to address outpatient care experiences. The OIG identified concerns with institutional disclosures for sentinel events. Leaders were generally knowledgeable within their scope of responsibilities about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued 9 recommendations for improvement in 4 areas:(1) Leadership and Organizational Risks• Institutional disclosures for sentinel events(2) Quality, Safety, and Value• Designated systems redesign and improvement coordinator• Surgical work group attendance(3) Care Coordination• Inter-facility transfer form completion• Active medication list transmission(4) High-Risk Processes• Disruptive behavior committee meeting attendance• Patient notification of behavioral restriction order• Staff training

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 Oklahoma City VA Health Care 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; 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.The healthcare system’s executive leadership team appeared stable; all positions were permanently assigned, and the team had worked together for over two years. The Director, who was assigned in June 2016, was the most tenured leader. The Assistant Director, assigned in May 2018, was the newest executive leader. Employee survey data revealed opportunities for the Associate Director of Patient Care Services, Associate Director, and Assistant Director to improve employee feelings of moral distress at work. Patient experience survey results highlighted challenges with outpatient care. The OIG’s review of the system’s accreditation findings, sentinel events, and disclosures 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 sustain and improve performance.The OIG issued five recommendations for improvement in four areas:(1) Registered Nurse Credentialing• Primary source verification of registered nurses’ licenses(2) Mental Health• Suicide prevention training(3) Care Coordination• Monitoring and evaluation of patient transfers(4) High-Risk Processes• Disruptive behavior committee attendance• Staff training

To determine delivery windows and expected arrival times, the Postal Service has specific service standards. These standards may seem like simple ranges of days, but behind them is a complex system that accounts for factors about each mailpiece, such as the type of mail it is and where and when it is entered into the postal network. In this report, the OIG provides an overview of how service standards for the delivery of mail and packages are established and defined, service performance is measured, and standards are revised.