Federal Reports

OIG performed agreed-upon procedures for assessing information reported by USDA’s NFC.

We issued this management alert to advise the Department of Homeland Security and United States Coast Guard (Coast Guard) of a risk to the health and safety of personnel posed by using functional firearms (emptied of ammunition) during Digital Versatile Disc (DVD)-based simulation training. After receiving our draft management alert, the Coast Guard took immediate corrective actions to discontinue the use of functional firearms during DVDbased simulation training.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Fayetteville VA Coastal Health Care System in North Carolina to assess concerns related to the quality, coordination, and timeliness of care, and the impact of COVID-19 on a patient with unintentional weight loss who was later diagnosed with oral cancer and died at another VA medical center.The OIG substantiated that the primary care provider and dietitians did not provide quality care to the patient. The primary care provider’s failure to follow-up on an earlier finding and not place an order for a medical test may have led to a delay in the patient’s cancer diagnosis. Dietitians conducted incomplete nutritional assessments given the patient’s declining nutrition status and may have contributed to a delay in diagnosis.The OIG determined that the patient’s PACT nurse and dietitians failed to coordinate care by not communicating the family’s request for a face-to-face appointment and the patient’s declining nutritional status to the primary care provider. The lack of care coordination may have contributed to a delay in examination and diagnosis.The OIG found that incorrect scheduling resulted in the patient not being seen by a dietitian for a follow-up appointment, and that a delay in scheduling a non-VA dental appointment occurred. The OIG concluded that COVID-19 impacted the care provided by dietitians because of the use of telephone visits, which did not allow dietitians to visually assess the patient’s physical characteristics caused by a declining nutritional status.The OIG made six recommendations related to completion of nutrition assessments, care coordination between PACT nurses and primary care providers, guidance on care coordination between dietitians and primary care providers, scheduling of dietitian and non-VA dental appointments, and evaluation of COVID-19 scheduling practices and impact on patient care.

Objective: To (1) evaluate internal controls over the accounting and reporting of administrative costs by the Puerto Rico Disability Determination Services (PR-DDS) 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: 5 of 20 recommendations not published (sensitive).

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 North Florida/South Georgia Veterans Health System, which includes the Malcom Randall VA Medical Center in Gainesville and the Lake City VA Medical Center . 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 review, the assistant director position had been vacant since 2019, with the Deputy Director and the Associate Director, Lake City sharing the responsibilities. All but one of the assigned leaders had worked together for over one year. Employee survey data revealed satisfaction with leadership and a workplace where staff felt respected and discrimination was not tolerated. Selected patient experience scores implied general satisfaction. However, survey results also highlighted opportunities to improve satisfaction for male and female veterans 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 six recommendations for improvement in four areas:(1) Quality, Safety, and Value• Surgical work group attendance(2) Registered Nurse Credentialing• Primary source verification(3) Care Coordination• Receiving physician identification• Medication list transmission(4) High-Risk Processes• Staff training