Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns related to Ralph H. Johnson VA Medical Center (facility) staff’s management of a patient’s reported perpetration of intimate partner violence (IPV). The OIG also evaluated concerns related to the IPV Assistance Program (IPVAP) implementation at the facility.The OIG found that despite the patient’s and spouse’s IPV reports, inpatient mental health unit staff did not consult with the IPVAP point of contact or ensure the spouse felt safe with the patient returning home upon discharge. The inpatient psychiatry resident did not timely complete a progress note addendum, which resulted in other clinicians not having access to critical IPV related information for 34 days. Facility staff failed to consider consultation with the Office of Chief Counsel although the Veterans Health Administration (VHA) advises employees to “work with your Office of Chief Counsel” regarding state reporting requirements for victims of IPV. Outpatient mental health staff did not consult with the IPVAP point of contact or document discussion of IPV resources or treatment options, as the OIG would have expected. The Facility Director did not ensure development of an IPVAP protocol, as required, and although a licensed independent provider was appointed as the IPVAP coordinator, facility staff and leaders did not identify the assigned IPVAP coordinator as a resource at the time of the patient’s care in 2019. The OIG also found that VHA guidance about IPV training responsibilities was unclear.The OIG made one recommendation to the Under Secretary for Health related to IPV training guidance and three recommendations to the Facility Director related to staff consultation with the IPVAP coordinator, timely clinical documentation, and consultation with the Office of General Counsel to determine reporting requirements.

We found that NPS employees did not follow compliance and protection requirements for archeological resources in Virgin Islands National Park.

Every Postal Service-owned vehicle is assigned a Voyager credit card to pay for its commercially purchased fuel, oil, and routine maintenance. OIG data analytics identified offices with potentially fraudulent Voyager card activity. The Wilmington, NC, Magnolia Station had 1,713 transactions at risk from October 1, 2020, through March 31, 2021, totaling $41,211. This included 282 Voyager card fuel purchases conducted with one employee’s PIN and valued at $6,084 and 60 transactions flagged as high-risk in FAMS. The objective of this audit was to determine whether Voyager card PINs were properly managed, and Voyager card transactions were properly reconciled at the Wilmington, NC, Magnolia Station.

Final Management Letter: Review of the SEC's Compliance With CISA ED 21-01 and Initial Response to the SolarWinds Compromise

John Pangelinan, a medical marketer based in Los Angeles was sentenced on August 2, 2021, to time served and two years’ probation for conspiracy to commit honest services mail fraud and health care fraud. Pangelinan brokered kickbacks and bribe payments to doctors in exchange for their referrals of compounded medications, durable medical equipment, and other health care goods to certain providers.Our investigation found that Pharmacy Acquisition LLC provided medically unnecessary compounded drug prescriptions to Precise Compounding Pharmacy that were reimbursed by health care benefit programs, including Amtrak’s plan. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $22,000.

The OIG determined whether VA complied with the requirements of the Payment Integrity Information Act of 2019 (PIIA) for fiscal year 2020. Several requirements focus on improper payments, or any payment that should not have been made or was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements.The review team found that VA did not comply with PIIA because it did not satisfy two of six requirements:• to meet reduction targets for two programs assessed to be at risk for improper payments, and• report an improper payment rate of less than 10 percent for five VA programs and activities that had improper payment estimates in the materials accompanying the annual financial statement.VA satisfied the other four requirements:• to post the annual financial statement for the most recent fiscal year and accompanying materials on PaymentAccuracy,• publish improper payment estimates for programs susceptible to significant improper payments in these materials,• publish corrective action plans for each program for which an estimate above the statutory threshold was published in these materials, and• conduct improper payment risk assessments for each program with annual outlays greater than $10 million at least once in the last three years.In fiscal year 2020, VA reported improper payment estimates totaling $11.37 billion for 12 programs and activities. To VA’s credit, it noted a decrease in improper payment estimates two years in a row and a decrease in its improper payment rates for nine programs and activities.The OIG recommended the under secretary for benefits ensure the Pension Program meets its reduction target. The OIG also recommended the acting deputy under secretary for health ensure the Purchased Long-Term Services and Supports Program meets its reduction target and reduce improper payments for five VA programs to below 10 percent.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Roseburg VA Health Care System, which includes the Roseburg VA Medical Center and three outpatient clinics in Oregon. The inspection covers 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; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.When the team conducted this inspection, the healthcare system’s leaders had worked together for 16 months, with the most tenured leader permanently assigned in 2016. Survey results revealed opportunities to improve staff feelings of “moral distress” in the workplace. Patients appeared generally satisfied, but there were opportunities to improve the experiences of women veterans.The OIG identified concerns with root cause analysis action implementation and outcomes measurement. Leaders were knowledgeable about employee satisfaction and patient experiences. However, they had opportunities to improve their knowledge of VHA data and/or system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures.The OIG issued 13 recommendations for improvement in six areas:(1) Quality, Safety, and Value• Root cause analyses(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit reviews(3) Mental Health• Staff training(4) Care Coordination• Goals of care conversations(5) Women’s Health• Designated women’s health providers• Women veterans health committee(6) High-Risk Processes• Standard operating procedures• Staff training• Monthly staff continuing education