Federal Reports

Management Challenges and Performance Challenges

The VA Office of Inspector General (OIG) evaluated allegations that facility leaders failed to address nurse staffing shortages yet continued to accept resident admissions and that the shortages contributed to adverse events, environment of care concerns, and infection control issues. The OIG further assessed allegations that the Community Living Center (CLC) did not have 24-hour housekeeping aides available, was dirty and infested with flying insects, CLC staff did not wash their hands, the CLC was quarantined more than two times during a 12-month period, a contracted staffing company (registry agency) was not meeting the requested number of nursing assistants (registry staff), and registry staff did not have access to residents’ electronic health records (EHRs). The OIG substantiated that facility leaders failed to address CLC nurse staffing shortages yet continued to accept admissions. The OIG was unable to determine if insufficient CLC staffing levels led to adverse events. However, the OIG identified a higher potential for an adverse clinical outcome related to a missing resident. The facility missed an opportunity to further analyze the event. Facility leaders reduced the number of operating beds without VHA authorization. Managers increasingly relied on registry staff, but the registry agency inconsistently supplied the requested number of staff. The Staffing Methodology Coordinator had insufficient knowledge and used inaccurate staffing targets. The OIG substantiated that 24-hour Environmental Management Service was not available; CLC staff were not consistently meeting the facility hand-hygiene compliance goal; one or both CLC floors closed to admissions and visitors between 2018 and 2019, but CLC staff followed identified processes to minimize additional exposures; and registry staff did not have access to EHRs and could not document care. The OIG did not substantiate that the CLC was dirty but substantiated the presence of flying insects. The OIG made ten recommendations to the facility director.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate concerns that the failure to follow pharmacy and nursing policies and procedures may have contributed to a patient’s death at the Southeast Louisiana Veterans Health Care System in New Orleans (facility). Following a code blue on the medical-surgical unit, a patient with multiple medical conditions was transferred to the intensive care unit (ICU). The patient’s provider ordered intravenous (IV) fentanyl (a controlled substance) and IV norepinephrine. Due to the patient transferring to the ICU, new medication orders entered previously were discontinued. As a result, an ICU nurse was unable to scan the IV fentanyl label. Another ICU nurse called the pharmacy for a new IV fentanyl label. A pharmacy staff member failed to follow the intent of the facility policy and sent an unattached IV norepinephrine label to the ICU. Subsequently, another ICU nurse incorrectly affixed the IV norepinephrine label to the IV fentanyl bag. The ICU nurse failed to follow facility policy by not verifying the patient and medication information prior to affixing the incorrect label. The patient received the IV fentanyl, mislabeled as IV norepinephrine, at rates not prescribed. ICU nursing staff also failed to follow the infusion rate orders and did not assess the effectiveness of the medication or complete documentation to ensure an accurate record of medications administered. Additional concerns identified during the OIG inspection included an unsecured IV controlled substance and the facility did not conduct a thorough review of the medication error. The OIG made eight recommendations related to unaffixed medication labels; medication administration, medication orders, and compliance with Veterans Health Administration and facility policies regarding high-alert and high-risk medications; security of controlled substances; submitting Joint Patient Safety Reports; peer review; and institutional disclosure.

The Unaccompanied Alien Children ProgramThe UAC program funds temporary shelter care and other related services for unaccompanied children in ORR custody. For project periods with services beginning during FYs 2014 and 2015, ORR awarded grants totaling $2.1 billion to providers for the care and placement of children. The UAC program is separate from State-run child welfare and traditional foster care systems.By law, HHS must provide for the custody and care of a UAC, defined as a child who has no lawful immigration status in the United States, who has not attained 18 years of age, and with respect to whom there is no parent or legal guardian in the United States available to provide care and physical custody (6 U.S.C. § 279(g)(2)). The Flores Settlement Agreement established a nationwide policy for the detention, treatment, and release of UAC and recognized the particular vulnerability of UAC while detained without a parent or legal guardian present (Flores v. Meese—Stipulated Settlement Agreement (U.S. District Court, Central District of California, 1997)).Under the Homeland Security Act of 2002, Congress transferred the care and custody of UAC to HHS from the former Immigration and Naturalization Service to move toward a child welfare-based model of care and away from the adult detention model. In the Trafficking Victims Protection Reauthorization Act of 2008, which expanded and redefined HHS’s statutory responsibilities, Congress directed that each child must “be promptly placed in the least restrictive setting that is in the best interest of the child” (8 U.S.C. § 1232(c)(2)).Care ProcessYFT, a nonprofit entity, is an ORR funded, faith-based shelter care provider in Bristow, Virginia. YFT also serves other adolescents in a separate residential program at its main campus and provides behavioral health services to the general public at various locations throughout the region. Since 2012, YFT has participated in ORR’s UAC program and served approximately 1,000 children. During our audit period, YFT’s ORR funded program received $9.2 million in Federal funds for the care and placement of 266 children.

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Making accurate and consistent decisions on disability compensation claims is vital to ensuring eligible veterans receive their benefits. The Veterans Benefits Administration (VBA) uses the Quality Review and Consistency Program (consistency study program) to ensure accurate and timely claims processing. The VA Office of Inspector General (OIG) examined whether VBA managed the consistency study program to improve uniformity in processing disability benefits claims. This review is one in a series of five reports regarding VBA’s quality assurance program. The consistency study program identifies error trends in quality reviews to develop consistency studies for claims processors. The program completed 60 consistency studies from October 1, 2015, through April 30, 2019, and conducted required training. However, the OIG found VBA missed opportunities to drive nationwide uniformity in claims processing. For example, the Compensation Service could have shared more accessible information with regional offices on their claims processors’ knowledge and performance. VBA’s Office of Field Operations (OFO) also did not ensure all claims processors participated in required studies, nor did staff follow up on study results to ensure improvements were made. The office was reported to have prioritized productivity over accuracy. The OIG concluded OFO should require regional office managers to take corrective action on consistency study results to improve accuracy and staff performance. Overall, VBA lacked strong processes for sharing and monitoring study results and could capitalize on information it already collects to help close knowledge gaps and improve the consistency of claims decisions. Recommendations include that the Compensation Service ensure detailed consistency study reports go to OFO and all regional office managers. OFO should also develop a process to monitor regional offices to increase employee participation in consistency studies and require regional managers to review study results to address performance issues.