Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to determine the validity of an allegation that a patient who sought treatment for insomnia and was out of psychiatric medications did not receive the care needed at the Memphis VA Medical Center (facility) in Tennessee. The patient died by suicide the day following a visit to the facility’s emergency department. The OIG substantiated that the patient presented to the facility’s emergency department for insomnia and psychiatric medication refills. The emergency department physician documented evaluating the patient and after a negative screen for suicidal thoughts, discharged the patient with instructions to go to the facility’s outpatient mental health clinic immediately for medication management. The OIG found no documentation that the patient registered or received treatment in the clinic. The OIG found the patient did not receive the care needed and the facility did not have a clear referral process for patients discharged from the emergency department who needed to be seen the same day in the outpatient mental health clinic.The patient received primary care from the facility and mental health care through the community. Several community care counseling sessions were not authorized timely due to deficiencies in coordination of care between the facility’s community care staff, community care providers, and the third-party administrator. Facility community care staff did not obtain medical record documentation for community care treatment and did not ensure care authorizations were current, resulting in the patient’s inability to receive several medication refills from the facility pharmacy. Facility leaders were aware of the patient’s death by suicide within three days of the patient’s death; however, the OIG could not find evidence that executive leaders were notified or that the family was contacted. The OIG made 16 recommendations to the facility director.

Our objective was to determine opportunities for the District to mitigate stamp stock shipment losses.

What We Looked AtThe United States has the largest and most diverse general aviation community in the world. In 2017, the Federal Aviation Administration (FAA) issued a new rule, referred to as BasicMed, which implemented an alternative way for many general aviation pilots to establish medical eligibility without having to undergo the previous medical certification process. As of April 2020, more than 55,000 pilots had been registered for BasicMed. To aid in their oversight of the new BasicMed process, then Chairmen Bill Shuster of the House Committee on Transportation and Infrastructure and Frank A. LoBiondo of the Subcommittee on Aviation requested that we examine FAA's implementation of the new BasicMed requirements. Our audit objectives were to assess FAA’s (1) procedures for implementing new medical requirements for certain small aircraft pilots, including identifying challenges to its implementation, and (2) plans for measuring the impact of the new BasicMed process on aviation safety. What We FoundFAA issued the BasicMed rule in compliance with the Act on January 11, 2017, and provided guidance and conducted outreach to stakeholders to implement the program. Under BasicMed, pilots can fly an aircraft the moment they complete the online medical course and submit other required information. However, FAA lacks an effective process to confirm pilots meet all eligibility requirements, such as whether they have a valid U.S. driver’s license. FAA also does not have a process to verify that pilots’ medical examinations are being performed by State-licensed physicians as required. In addition, FAA’s plan to measure the safety impact of the program is limited by a lack of available data. According to FAA, it may take several more years until there is sufficient data to identify trends and evaluate the rule’s safety impacts, due in part to the lengthy process for accident investigations. Our RecommendationsFAA concurred with our two recommendations to improve FAA’s process for verifying pilot’s eligibility for the BasicMed program and measuring the program’s impact on aviation safety.