Federal Reports

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.

In fiscal year (FY) 2020, the Postal Service used about 255,000 delivery vehicles to distribute mail to 160 million delivery points across the nation. While about $292 million was spent on vehicle parts through 16 suppliers, the Postal Service spent about $190 million (65 percent) with two primary consignment vehicle part suppliers.These suppliers are contracted through national ordering agreements for the sale of vehicle parts through consignment with a period of performance from 2007 to 2050. The agreements also include a most favored customer pricing clause which allows the Postal Service to obtain an equal to or lower unit price for vehicle parts provided to the suppliers’ other customers.Our objective was to assess if the management of Postal Service vehicle parts agreements is consistent with pricing requirements.

Our objective for this report was to assess the effectiveness of the company’s efforts to achieve compliance with the Americans with Disabilities Act.We found that the company has clearer lines of authority, responsibility, and accountability for the Americans with Disabilities Act (ADA) program, and that its reorganization, based on our prior recommendations, has helped it bring 36 more stations into compliance since October 2017 through April 2021. The company cannot, however, reasonably expect to execute its aggressive plan to achieve compliance at the remaining 312 stations over the next six years until it develops the requisite planning to achieve its timeline. Although the company appears fully committed to achieving ADA compliance, it acknowledges that it currently does not have enough staff to manage additional projects or monitor the contractors it hired to support them. We also found that achieving cooperation with third parties at the remaining noncompliant stations remains a significant program risk. Finally, we found that Amtrak’s Information Technology department and its ADA Stations team did not coordinate to ensure that passenger information display systems (PIDS) installations were compliant, and they did not effectively coordinate to ensure that they were tracking the same number of stations at which the company is responsible for PIDS, which led to inconsistent reporting.We recommended that the company 1) assess the current and future resources the ADA program needs to implement its timeline, including resources from other groups, and identify actions to address any shortfalls, 2) ensure it reviews contractor timesheets and invoices more thoroughly, reconcile contractor timesheets and invoices from fiscal year 2015 through fiscal year 2020, and, if applicable, recover any costs, 3) develop guidance that institutionalizes steps program staff can take when they reach a stalemate with a third party, and 4) take and document actions to ensure the ADA Stations team and Information Technology department are coordinating so installations are compliant and reporting is consistent and accurate. 

An Amtrak passenger conductor based in Florence, South Carolina, was terminated from employment on September 2, 2021, following his administrative hearing. Our investigation found that the former employee violated company policy by engaging in outside employment while on a medical leave of absence from the company and by being dishonest on his pre-employment physical exam form when responding to questions regarding previous injuries and hospitalizations.