Federal Reports

To view a set of interactive dashboards with up-to-date data on COVID-19 cases in this facility, click the link below.

To view a set of interactive dashboards with up-to-date data on COVID-19 cases in this facility, click the link below.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Nashville VA Medical Center in Tennessee to evaluate alleged deficiencies in cardiac telemetry monitoring services including policies, staffing, and communication. The OIG did not substantiate • The system’s policy related to telemetry monitoring and practices was outdated, • Staffing shortages or inadequate training of staff performing telemetry monitoring, • Telemetry patients with “do not resuscitate” orders did not receive clinically appropriate interventions, or • Nursing staff had knowledge deficits related to the care of telemetry patients with do not resuscitate orders. However, there were identified isolated communication issues between telemetry technicians and telemetry patient nurses related to the specific location and movement of telemetry patients while in the hospital. The OIG did not make a recommendation since an electronic patient tracking system was available in case of an emergency. In addition, in 2018, facility leaders identified other telemetry communication issues. The OIG reviewed facility leaders’ actions and noted overall improvement since staff training in February 2019. Therefore, the OIG made no recommendation. The OIG identified improper reusable medical equipment practices with the return of used and contaminated telemetry boxes and the location of clean supplies. System leaders took immediate steps and the OIG determined that no further action was indicated. The OIG determined the rapid response team policy and staff practice regarding the initiation of a rapid response team call did not always align, which is important to mitigate system vulnerabilities. The OIG made one recommendation to the Tennessee Valley Healthcare System Director to ensure consistency between the system’s policy and actual practice for initiating a rapid response team call.

OIG conducted the audit of Peace Corps/Ghana from July 15, 2019 to August 2, 2019. Our overall objective in auditing overseas posts is to determine whether the financial and administrative operations are functioning effectively and in compliance with Peace Corps policies and Federal regulations. The post’s financial and administrative operations required improvement to comply with agency policies and applicable Federal laws and regulations. Our report contains 52 recommendations directed to both the post and headquarters. Our recommendations included strengthening controls over managing imprest funds, Volunteer payments, property accountability, grants management, security certifications, financial management system access, and bill of collections; ensuring that contracts are adequately executed, and purchases are adequately authorized.

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 Kansas City VA Medical Center and multiple outpatient clinics in Kansas and Missouri. 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 leaders were permanently assigned. Employee satisfaction survey results revealed opportunities for the Associate Director for Patient Care Services to improve employee engagement and empowerment. Patients appeared generally satisfied with the care provided. Review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risks. Executive leaders were generally knowledgeable within their scope of responsibilities contributing to specific poorly performing Strategic Analytics for Improvement and Learning quality measures. However, the OIG noted that only 6 of 29 VHA quality metrics showed high performance compared to other facilities, indicating multiple opportunities exist for improvement. The OIG issued 20 recommendations for improvement in seven areas: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • Medication storage • Clinic privacy (4) Medication Management • Behavior risk assessment • Urine drug testing • Informed consent • Follow-up after therapy initiation • Pain Management Committee processes (5) Mental Health • Suicide prevention training (6) Care Coordination • Life-Sustaining Treatment Decisions Committee processes (7) High-Risk Processes • Risk analysis • Airflow monitoring • Environmental safety • Equipment storage • Staff training