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 Ann Arbor VA Medical Center and multiple outpatient clinics in Michigan and Ohio. 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.The medical center executive leadership team appeared stable. All positions were permanently assigned and only the assistant director had been in the role for less than a year. Employee survey items revealed that leaders appeared to have created a positive workplace environment where employees felt safe bringing forth issues and concerns. Patient experience survey data indicated satisfaction with inpatient care provided and highlighted opportunities to improve veterans’ experiences in the outpatient settings. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. 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 nine recommendations for improvement in five areas:(1) Quality, Safety, and Value• Improvement action implementation(2) Medical Staff Privileging• Ongoing professional practice evaluations• Provider exit reviews(3) Mental Health• Suicide safety plans• Staff training(4) Women’s Health• Women Veterans Health Committee structure and reporting(5) High-Risk Processes• Daily cleaning schedule• Storage and reprocessing areas temperature and humidity• Staff continuing education

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements

The OIG conducted a joint investigation with the U.S. Department of Transportation’s Office of Inspector General into allegations that a tribal transportation consortium fraudulently received more than $9 million between 2012 and 2015 by collecting Bureau of Indian Affairs (BIA) Roads Funds for tribes no longer affiliated with the consortium.We did not substantiate the allegations. We identified 24 tribes that were members of the consortium, and none of the representatives we spoke to corroborated the allegations. None of the representatives from tribes that had withdrawn from the consortium provided evidence that the consortium continued to collect their tribe’s BIA Roads Funds after they left.The consortium is a defunct entity and has not received BIA Roads Funds since 2015.

The OIG investigated allegations that a service-disabled veteran-owned small business (SDVOSB) acted as a pass-through entity to enable another company to obtain SDVOSB contracts that it was not eligible to receive. It was further alleged that the veteran identified as the SDVOSB’s owner had little or no involvement in the day-to-day operation of the SDVOSB.We found that the SDVOSB and the other company used the SDVOSB’s status to obtain approximately $3.5 million in U.S. Department of the Interior (DOI) SDVOSB contracts, which the other company would not otherwise have been eligible to receive. The SDVOSB shared the large company’s office space, support services, and staff, which were in Arizona, even though the SDVOSB was based outside of Arizona. Further, both the SDVOSB and the other company registered or updated System of Award Management profile records on the same days, using the same unique IP address. We also found no evidence that the SDVOSB’s veteran owner, who resided outside of Arizona, was involved in the day-to-day operations of the SDVOSB, even though this is a requirement to receive SDVOSB status.The U.S. Attorney’s Office for the Southern District of Arizona declined both criminal and civil prosecution of this matter. We have referred both the SDVOSB and the other company to our Administrative Remedies Division for consideration of suspension or debarment.