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 Birmingham VA Medical Center and multiple outpatient clinics in Alabama. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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. At the time of this inspection, the medical center’s leaders had been working together for four days. Employee satisfaction scores were generally similar to or better than VHA averages. Selected patient experience scores generally reflected similar or lower ratings than the VHA average. The OIG’s review of the medical center’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the OIG identified a repeat finding related to dirty floors in patient care areas. The executive leaders were extremely knowledgeable within their scopes of responsibilities about VHA data and/or system-level factors contributing to specific poorly performing Strategic Analytics for Improvement and Learning measures. The OIG issued 18 recommendations for improvement across seven areas: (1) Quality, Safety, and Value • Root cause analyses (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • Cleanliness and infection prevention procedures • Patient health information protection (4) Medication Management • Aberrant behavior risk assessment • Concurrent opioid and benzodiazepine therapy • Urine drug testing • Informed consent (5) Mental Health • Suicide safety plans • Suicide prevention training (6) Women’s Health • Women’s health primary care providers (7) High-Risk Processes • Annual risk analysis

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 Central Alabama Veterans Health Care System and multiple outpatient clinics in Alabama and Georgia. The inspection covers key clinical and administrative processes associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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 executive leadership team had vacancies in four of the five key positions. The director, associate director for patient care services, and associate director roles had been vacant for at least six months; the chief of staff position had been vacant for two years. The Deputy Director was the only permanently-assigned leader. Employee satisfaction and patient experience survey scores were generally lower than VHA averages. Executive leaders were generally knowledgeable about facility Strategic Analytics for Improvement and Learning (SAIL) measures, but lacked understanding of Community Living Center SAIL measures. The OIG issued 30 recommendations for improvement in eight areas:(1) Quality, Safety, and Value • Peer review processes • Utilization management processes • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Environmental cleanliness (4) Medication Management • Behavior risk assessment • Concurrent therapy • Urine drug testing • Informed consent • Patient follow-up • Pain committee (5) Mental Health • Patient follow-up • Staff training (6) Care Coordination • Goals of care conversations (7) Women’s Health • Women Veterans Health Committee • Quality data monitoring (8) High-Risk Processes • Annual risk analysis • Airflow testing • Staff training

Our objective was to determine mailer compliance with Negotiated Service Agreement (NSA) provisions and evaluate the U.S. Postal Service’s oversight of NSA Contract #50593050. We selected the NSA based on the mailer’s 2019 volume and revenue.

Our objective was to assess the Social Security Administration's (SSA) actions to expand oversight of its hearing process after the Huntington fraud scheme, which involved an administrative law judge (ALJ).

Our objective was to assess the effectiveness of management controls over recoveries for private party damage to U.S. Postal Service vehicles.

OIG identified monitoring and reporting on the integrity of HHS programs, including responsible stewardship of HHS programs and protection of resources, as a top management and performance challenge for HHS. NIH operations are responsible for the prudent management and careful stewardship of approximately $1.8 billion in accountable personal property. The Department of Defense and Labor, Health and Human Services, and Education Appropriations Act, 2019 and the Continuing Appropriations Act, 2019, P.L. No. 115-245, provided HHS OIG with $5 million from the NIH appropriation for oversight of grant programs and operations of NIH.Our objective was to determine whether NIH had controls in place to effectively and efficiently track and monitor information technology (IT) resources and internet protocol (IP) addresses.

Our objective was to assess the cost, schedule, and technical performance of the Program’s acquisition and development effort for selected instruments. We found the following: (1) The Program exceeded contract definitization timelines and conducted late and abbreviated baseline reviews. (2) JPSS-2 Cross-track Infrared Sounder quality assurance did not adequately integrate contract risks into its surveillance activities. (3) Award-fee determinations did not motivate the contractor toward exceptional performance. We recommend that the NOAA Deputy Undersecretary for Operations do the following: (1) Require programs notify the Joint Agency Program Management Council before NOAA-funded NASA contracts exceed definitization timelines. (2) Require a Joint Agency Program Management Council assessment before an Integrated Baseline Review requirement is removed, abridged, or its timing adjusted, for NOAA-funded NASA contracts or major contract modifications requiring earned value management. We recommend that the NOAA Assistant Administrator for Satellite and Information Services do the following: (3) Ensure the Program adequately incorporates contract risks and executes prevention-focused surveillance as part of its quality assurance activities. We recommend that the NOAA Assistant Administrator for Satellite and Information Services coordinate with the Director of the NASA Goddard Space Flight Center to do the following: (4) Conduct a joint review of contractor performance evaluation practices and determine whether changes could more effectively motivate contractors to achieve desired outcomes for ongoing and future contract negotiations on NOAA-funded projects. (5) Establish a working definition of “significant” cost overrun to help inform strategies that progressively motivate contractors to improve before accumulating excessive cost and schedule performance deficits, for ongoing and future NOAA-funded NASA contracts.