Federal Reports

A former Machinist based in Albany-Rensselaer, New York, violated company policies by viewing pornographic videos during work hours on his company-owned computer. The videos were stored and accessed on a USB device. He admitted to viewing the videos and resigned on June 18, 2020, following his interview by Office of Inspector General special agents. The former employee is not eligible for rehire.

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 VA Eastern Kansas Health Care System and multiple outpatient clinics in Kansas and Missouri. The inspection covers key clinical and administrative processes associated with promoting quality care. The 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 been working together for two months, although the Director had served since 2012. Survey results revealed opportunities to improve employee satisfaction; however, patients appeared satisfied. Leaders were unable to speak knowledgeably about actions taken to maintain and improve performance and were minimally knowledgeable about Strategic Analytics for Improvement and Learning and community living center data. The OIG issued 39 recommendations for improvement in these seven areas: (1) Quality, Safety, and Value • Committee activities • Peer review processes • Utilization management processes • Root cause analysis processes (2) Medical Staff Privileging • Professional practice evaluations • Provider exit review processes (3) Environment of Care • General safety • Environmental safety and cleanliness • Medical supply storage and availability • Panic alarm testing • Privacy protection (4) Medication Management • Urine drug testing • Informed consent documentation • Follow-up after therapy initiation (5) Mental Health • Outreach activities • Suicide prevention care (6) Women’s Health • Community-based outpatient clinic-designated women’s health primary care providers • Women Veterans Health Committee processes (7) High-Risk Processes • Inventory file and standard operating procedures • Annual risk analysis • Airflow testing and equipment storage • Staff training

The VA Office of Inspector General (OIG) conducted this inspection to evaluate concerns related to a Virtual Pharmacy Services (VPS) pharmacist’s discontinuation of an antidepressant medication for a patient of the Minneapolis VA Health Care System, which resulted in the patient not having prescribed antidepressant medication for approximately six weeks before dying by suicide. The OIG found the VPS pharmacist did not access the patient’s electronic health record or notify the psychiatrist when discontinuing an antidepressant medication order. Although the facility granted the VPS pharmacist access to the patient’s electronic health record, the pharmacist reported not being aware of this capability. The discontinuation of the patient’s medication may have contributed to increased depressive symptoms, including suicidal ideation, in the six weeks following the patient’s scheduled completion of the medication. The OIG was unable to determine that the medication discontinuation contributed directly to the patient’s death; however, the possible worsening of the patient’s underlying depressive illness may have been a contributing factor. The OIG identified discrepancies between VPS pharmacists’ duties outlined in their functional statement and duties actually performed. VPS pharmacists’ inability to fully execute certain functions may contribute to decisions that are not fully informed and patients may not receive medications as prescribed. The VPS productivity measure of 95 prescriptions processed per hour might be an unreasonable target and may contribute to increased risk for pharmacist error. Further, Pharmacy Benefits Management leaders did not ensure VPS prescription processing was adequately monitored for accuracy. Pharmacy Benefits Management leaders failed to clearly outline program management and quality assurance monitoring objectives and processes leading to deficiencies that can contribute to adverse patient outcomes. The OIG made five recommendations to the Under Secretary for Health related to standardizing software menu options, revising functional statements and performance metrics, and establishing certain quality assurance objectives.

OIG evaluated FSIS’ controls over meat, poultry, and egg product labels to ensure FSIS’ approval of labels was accurate and supported.

We audited the Los Angeles County Development Authority’s Family Self-Sufficiency Program due to a hotline complaint (HC-2019-4215) alleging that the Authority did not use its program funds in compliance with U.S. Department of Housing and Urban Development (HUD) requirements. Our audit objectives were to determine whether the Authority met its program goals and objectives to assist eligible families in becoming self-sufficient and administered its program in compliance with HUD requirements. In addition, determine whether the hotline complaint allegations of Authority employees misappropriating program funds for personal benefit had merit.We determined that the hotline complaint had no merit. The Authority met its goals and objectives to assist its participants in becoming self-sufficient and ensured that program funds were used in compliance with HUD requirements. Specifically, the Authority ensured that it (1) maintained the minimum program size; (2) provided participants with individual training and services plans, which included specific interim and final goals; (3) monitored participants’ progress to ensure that they met their goals to become self-sufficient; (4) calculated participants’ escrow accounts accurately; and (5) used program funds for supported and eligible activities.There are no recommendations.

A Coach Cleaner in New Orleans, Louisiana, was terminated from employment on June 18, 2020, following an administrative hearing for violating company policy. Our investigation found that the employee failed to report multiple arrests and criminal convictions for drug and weapons related charges during his tenure with the company. Specifically, we found that he failed to disclose his 2017 and 2019 arrests and their subsequent convictions to the company.