Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate an allegation that improper feeding by a registered nurse (RN) at the New York Harbor Health Care System’s Community Living Center (CLC) contributed to the death of a patient. The OIG identified concerns related to inaccurate electronic health record (EHR) documentation and an inadequate facility review of the patient’s care.The OIG substantiated that improper feeding during lunch by a CLC RN contributed to the death of a patient. Approximately five hours after being fed lunch when the patient was intubated, a piece of chicken was removed from the patient’s airway. A code team physician documented two EHR notes indicating a dimension of the chicken as .8 cm in one note and 8 cm in the second note. The OIG was unable to determine the exact size of the chicken but based on the information available, concluded that the chicken did not have a dimension of 8 cm but was larger than an appropriate size to feed to the patient.CLC nursing staff did not include accurate meal consumption documentation on the day at issue. Two staff members entered an EHR note which contained differing amounts of food the patient ate at breakfast. There was no documentation the patient ate lunch.The OIG determined that facility leaders did not complete a comprehensive review of the event. The Cardiopulmonary Resuscitation Subcommittee completed an insufficient review of the code by not determining the accuracy of the EHR documentation. No staff member submitted an incident report of the adverse clinical outcome. A clinical disclosure was completed but not an institutional disclosure.The OIG made seven recommendations to the Facility Director related to nursing competencies and training, feeding documentation, review of the patient’s care, committee oversight, incident reports, and institutional disclosure.

Information technology controls protect VA systems and data from unauthorized access, use, modification, or destruction. The VA Outpatient Clinic in Austin, Texas, is VA’s largest freestanding outpatient clinic— conducting almost 300,000 outpatient visits annually. The OIG inspected this clinic to determine whether it was meeting federal guidance in four security control areas related to configuration management, physical security, security management, and access controls.The team identified security deficiencies in the clinic’s configuration management controls related to component inventory and vulnerability and patch management. Although the inspection team and VA’s Office of Information and Technology (OIT) both used the same vulnerability scanning tools, OIT did not detect 150 of the 246 vulnerabilities the team identified. OIT’s standard vulnerability identification process and scans were ineffective. The poor component inventories and vulnerability management contributed to inadequate patch management. Without these controls, VA may be placing critical systems at unnecessary risk of unauthorized access, alteration, or destruction.The team also discovered three hard drives that potentially held personally identifiable information and personal health information that were not labeled or processed for sanitization. Media protection deficiencies like these increase the risk of unauthorized disclosure of veterans’ information.The team did not identify deficiencies with the maintenance, physical, and environmental security controls or security management and access controls. The clinic’s existing policies and procedures addressed these areas, and no recommendations were made for them.The OIG recommended maintaining an accurate inventory, implementing a more effective patch and vulnerability management program, distributing the media protection standard operating procedure, and ensuring compliance with the procedure’s labeling and sanitization provisions.

Due to the importance of switching and clearances being performed safely to avoid injuries and to minimize the possibility of unscheduled outages or equipment damage, we performed an evaluation to determine if switching and clearances, required training, and audits were performed in compliance with Transmission and Power Supply’s switching and clearance procedures. We determined the selected procedural requirements for requesting and tracking of switching and clearances were generally performed in accordance with procedures. We could not assess most procedural requirements related to preparation and performance of switching orders because field personnel performing the work do not always submit the completed switching order. However, we identified several instances where switching order steps were not performed in sequence as required. We also determined employees who performed key functions received required training; however, tracking of training could be improved. In addition, while clearance audits were completed by the appropriate personnel within the required time frames, their effectiveness could be increased.

We confirmed that 15 high-risk disaster relief purchases made by the BLM and the NPS were allowable and supported by DOI and bureau policy.

The North Royalton, Willoughby, and Jesse C. Owens Post Offices are in the Ohio 1 District. The Postal Service is required to maintain a safe and healthy environment for both employees and customers in accordance with its internal policies and procedures and Occupational Safety and Health Administration (OSHA) safety laws. Our objective was to determine if Postal Service management is adhering to building maintenance, safety and security standards, and employee working condition requirements at post offices.

Contract Delivery Service (CDS) is a contractual agreement between the Postal Service and an individual or firm for the delivery and collection of mail to and from homes and businesses. The Postal Service considers CDS to be one of its three primary delivery types, in addition to city carriers and rural carriers. CDS suppliers are not Postal Service employees, but independent contractors who provide delivery on specific routes not serviced by Postal Service mail carriers. The Postal Service manages CDS contracts within the transportation functional area, which consists of a wide variety of different contracts related to transportation. In fiscal year (FY) 2020, the Postal Service had more than 7,900 active CDS contracts, which cost a total of about $447 million. Our objective was to assess whether all CDS costs are accurately captured and reliably attributed to mail products and services.