Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 15: VA Heartland Network, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, the areas of focus were 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 15 facilities. The VISN’s executive leadership team appeared stable with the Network Director, Deputy Network Director, Chief Medical Officer, and Human Resources Officer serving together for the past four years. The Quality Management Officer joined the team in June 2019. Selected survey scores related to employee satisfaction and patient experience were similar to or higher than VHA averages. The OIG’s review of access metrics and clinical vacancies did not identify any substantial organizational risks. The executive team seemed to support efforts to improve and maintain positive outcomes (such as conducting site visits to improve performance and quality care for high-risk veterans and providing training for mental health and community living center staff). The team was also knowledgeable about Strategic Analytics for Improvement and Learning metrics but should continue to take actions to sustain and improve performance. The OIG issued 10 recommendations for improvement in four areas: (1) Quality, Safety, and Value • Utilization management annual summary review (2) Medication Management • Pain Management Strategy implementation and progress report • Pain committee establishment (3) Women’s Health • Interdisciplinary strategic planning activities • Quarterly program updates • Annual site visits • Educational resource development • Access and satisfaction data analysis • Maternity care outcome data tracking (4) High-Risk Processes • Facility corrective action plans

Our report contains 13 recommendations directed to the post and headquarters. We recommend that the post improve controls related to Volunteer bank account closure, billing and collection, and imprest funds. Additionally, we recommend that headquarters strengthen internal controls related to the administration of financial-system user roles and issue medical guidelines to comply with host country laws.

This audit report is one of a series of OIG reports that addresses the identification, reporting, and investigation of incidents of potential abuse and neglect of our Nation's most vulnerable populations, including Medicaid beneficiaries in nursing facilities.Nursing facility residents are at increased risk of abuse and neglect when healthcare professionals and caregivers fail to report abuse, or when incidents of potential abuse or neglect are not acted upon in a timely manner.

On the Quarterly Medicaid Statement of Expenditures for the Medical Assistance Program (Form CMS-64) for the quarter ended September 30, 2014, Indiana claimed increasing adjustments on Line 10A, Adjustments Decreasing Claims For Prior Quarters: Federal Audit (Line 10A). We audited Indiana's methodology in claiming the increasing adjustment.

This report is redacted for privacy reasons.

Program operations staff in the Veterans Benefits Administration (VBA) conduct site visits to regional offices to ensure that veterans service centers follow policies and procedures for disability compensation benefits. The VA Office of Inspector General (OIG) examined whether program operations staff conducted site visits and identified deficiencies at regional offices, and if managers took sufficient follow-up action on frequently identified errors to improve disability claims processing. The OIG found that program operations staff generally identified deficiencies during site visits and communicated results to the relevant offices, which addressed those deficiencies. VBA’s Compensation Service summarized the site visit findings on its internal website, which all regional office managers can review. Staff also conducted trend analyses of deficiencies and shared an informal summary of error trends each year with VBA’s Office of Field Operations, which is responsible for providing direction to regional offices. However, the Office of Field Operations did not fully use the information from site visits to improve claims processing nationwide. The deputy under secretary for field operations expected regional office managers to be aware of issues raised in other regional office site visit reports, but there was no written policy for addressing frequently identified errors. The OIG made three recommendations to VBA for achieving nationwide improvement in the consistency and accuracy of veterans’ claims decisions. These recommendations included a formal annual report from the Compensation Service to the Office of Field Operations on all recurring deficiencies and action items identified by the site visit program during the inspection year, and a recurring action plan to address them. The OIG also recommended that VBA establish a follow-up process to monitor compliance with the new requirement and hold regional office managers accountable for making corrections and addressing action items in a timely manner.

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 Robert J. Dole VA Medical Center and multiple outpatient clinics in Kansas. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were 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 worked together since 2018. The Director had served in the role since 2016. Employee satisfaction scores revealed opportunities for the Associate Director for Patient Care Services to improve employee attitudes towards senior leaders. Patients appeared satisfied with their care and leaders appeared actively engaged. The OIG identified significant concerns regarding incident review processes and identifying sentinel events and/or institutional disclosures. Leaders were able to speak knowledgeably about performance actions and survey results. Leaders were also generally knowledgeable about Strategic Analytics for Improvement and Learning data. The OIG issued 26 recommendations for improvement in all eight areas: (1) Quality, Safety, and Value • Utilization management data review • Root cause analysis processes • Annual patient safety report (2) Medical Staff Privileging • Professional practice evaluations • Provider exit reviews (3) Environment of Care • Supply storage • Environmental cleanliness • Privacy (4) Medication Management • Behavior risk assessment • Informed consent • Patient follow-up (5) Mental Health • Patient follow-up • Suicide safety plans • Staff training (6) Care Coordination • Multidisciplinary committee (7) Women’s Health • Women Veterans Health Committee membership (8) High-Risk Processes • Annual risk analysis • Airflow and infection control • Endoscope storage