Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 12: VA Great Lakes Health Care System in Westchester, Illinois, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection focused on Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Medication Management: Long-Term Opioid Therapy for Pain; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment. The OIG conducted this unannounced visit during concurrent inspections of VISN 12 facilities. The VISN executive leadership team appeared stable, with the Deputy Network Director, Chief Medical Officer, Quality Management Officer, and Human Resources Officer having served together for almost two years. The permanent Network Director was appointed on March 1, 2020. Selected survey scores related to employee satisfaction with the VISN executive team leaders were generally better than VHA averages. Overall patient experience survey scores were better than VHA averages; however, the VISN has an opportunity to help improve patient satisfaction with inpatient and specialty care. Executive leaders seemed to support efforts to improve and maintain patient safety, quality care, and other positive outcomes through utilization management training, improvement of hospital-wide readmission rates, and creation of a workgroup to improve case management and follow-up care. The leadership team was knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning metrics. The OIG issued four recommendations for improvement in one area, High-Risk Processes. The OIG recommended that reusable medical equipment inspections are conducted, and results are shared with executive leaders and posted within the required time frame; also, that reusable medical equipment corrective action plans are developed and tracked until closure.

Our objective was to (1) to determine whether the Social Security Administration (SSA) made payments to beneficiaries and/or representative payees who were deceased according to Kentucky's Office of Vital Statistics and (2) identify non-beneficiaries in the State files whose death information did not appear in Agency records.

As of October 2016, the Recovery School District in Louisiana (RSD)had received a $1.5 billion Public Assistance grant from Louisiana, a Federal Emergency Management Agency (FEMA) grantee, for damages resulting from Hurricane Katrina. We examined $1.3 billion for a consolidated project as part of the total amount awarded. In some instances, RSD accounted for and expended portions of the $1.3 billion in Public Assistance grant funds we reviewed according to Federal regulations. However, FEMA improperly awarded $216.2 million to repair or replace more than 292 Orleans Parish school facilities in RSD. We made eight recommendations to FEMA to de-obligate $216.2 million of ineligible costs; follow Federal regulations and FEMA guidelines; and re-evaluate documented proof of assessments for the 35 identified projects and reclassify them, as appropriate, to repair-eligible, and de-obligate the cost difference. FEMA concurred with recommendations 2 through 7 but did not concur with recommendations 1 and 8. We consider recommendations 2 through 7 resolved and open; recommendations 1 and 8 are unresolved and open.

The OIG investigated an allegation that a former Bureau of Land Management (BLM) employee accessed child pornography with a U.S. Government computer.We found no evidence that the employee accessed child pornography. We evaluated the employee’s network traffic, which showed their computer accessed sites hosting suspected child pornography; however, we were not able to determine if the employee accessed the areas of the websites that hosted the suspected child pornography. The employee took certain actions with respect to the hard drive, so we were unable to recover any images or other evidence from the computer. The employee admitted to viewing adult pornography on their Government computer while on duty but denied viewing child pornography.The employee resigned during our investigation after receiving a notice of proposed removal. The U.S. Attorney declined prosecution of this matter.

For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program’s drug rebate requirements, manufacturers must pay rebates to the States for the drugs. However, a prior OIG review found that States did not always invoice and collect all rebates due for drugs administered by physicians.Our objective was to determine whether Maine complied with Federal Medicaid requirements for invoicing manufacturers for rebates for physician-administered drugs.