Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection regarding allegations that a radiologist made gross errors resulting in treatment delays and placed misleading report addenda in records, and that leaders were tolerant of this practice. During the inspection, the OIG found evidence of manipulation and vulnerability of the electronic health record and mismanagement of the Medical Imaging Service. Facility leaders failed to successfully manage or address the impact of interpersonal conflicts within the Medical Imaging Service that included intimidation of staff radiologists. The OIG was concerned that ongoing interpersonal conflicts, coupled with the lack of defined plans for resolution, had the potential to adversely affect patient care. The OIG did not substantiate that the radiologist made addenda to cover gross errors resulting in treatment delays that contributed to adverse clinical outcomes for two patients or that the radiologist’s use of addenda was misleading. However, the date and location of addenda in radiology reports may hinder transparent communication of clinical information. Both Veterans Integrated Service Network and facility leaders failed to conduct a thorough and impartial review related to the OIG request to evaluate the original allegations. The OIG made eight recommendations including two addressed to the Under Secretary for Health regarding addenda, deletion, and formatting features for radiology reports in the new electronic health record, and an evaluation of the circumstances that led to the radiology manager’s deletion of an imaging report. Two recommendations to the Veterans Integrated Service Network 12 Director related to imaging archiving and communication system practices and oversight of OIG hotline case referrals. Four recommendations for the Facility Director focused on correction of the patient’s imaging study, Medical Imaging Service oversight and management, evaluation of Medical Imaging Service’s workplace culture, and evaluation of the need for workplace intimidation training and the process for reporting concerns.

The Office of the Inspector General audited TVA’s Insider Threat Program (ITP) to determine if TVA had a program established to address insider threats that was consistent with best practices. We found several areas where TVA’s ITP was consistent with best practices. Additionally, we found TVA had designated a senior official charged with overseeing classified information sharing and safeguarding efforts of the agency. Although TVA had not yet implemented its planned ITP, we determined TVA’s program will be at a proactive maturity level upon its planned implementation. We identified best practices that were not currently included in the developed ITP related to monitoring and awareness training. TVA management agreed with our recommendations.

Illinois' monitoring of childcare providers did not ensure provider compliance with State requirements related to criminal background checks at 12 of 30 childcare provider locations we reviewed. We found that 2 of 327 individuals did not obtain 1 or more of the required criminal background checks. Specifically, we found that the in-State criminal registry check was not conducted for one individual and all required background checks were not conducted for the second individual. In addition, 47 of 327 individuals had obtained all initial criminal background checks, but the required recurring checks were not conducted within the last 5 years. These errors occurred because Illinois did not effectively monitor the childcare provider criminal background checks. By not ensuring that all childcare staff members who supervised or had routine unsupervised contact with children passed all initial or recurring criminal background checks within the last 5 years, Illinois potentially jeopardized the safety of children in its care.

Health care coalitions (HCCs) help prepare their community health care systems to respond to public health emergencies, such as natural disasters. HCCs are member-led and are composed of health care entities and other response entities that voluntarily work together to coordinate an emergency response. ASPR supports HCCs through the Hospital Preparedness Program (HPP). The HPP funds awardees (e.g., States) to create HCCs, oversee HCCs, and fund HCC activities. In 2017, the HPP required HCCs to include four core member types (hospitals, public health, emergency medical services, and emergency management) and other diverse, ancillary member types (e.g., long-term-care facilities, home health agencies) that are critical to addressing the unique preparedness needs of HCCs' respective communities. Additionally, the Centers for Medicare & Medicaid Services (CMS) suggested that health care entities join HCCs as one way to meet Medicare's emergency preparedness Conditions of Participation, with which CMS required compliance starting November 2017.

The Medicaid "health home" option allows States to create programs that provide care coordination and care management for beneficiaries with chronic health conditions. Health homes are not physical spaces. Rather, they are a healthcare model in which providers work together to coordinate and manage beneficiaries' care at a reasonable cost.

What We Looked AtPreventing accidents in railroad operations that result from employees' illicit drug and/or alcohol impairment is critical to ensuring the safety of the traveling public. Illicit drug use discovered during investigation of fatal railroad accidents and a recent increase in the percentage of railway workers testing positive for drug use underscore the importance of the Federal Railroad Administration's (FRA) oversight of railroads' drug and alcohol testing programs. Given the importance of drug and alcohol testing to protecting transportation safety, our office is conducting a series of reviews on drug testing programs within the transportation industry. Our objectives for this self-initiated audit were to assess FRA's (1) review and approval of railroads' random alcohol and drug testing program plans, and (2) controls for enforcing compliance with the plans and minimum annual random alcohol and drug testing rates.What We FoundFRA has not adequately reviewed and approved railroads' drug and alcohol testing plans as required or documented its review and approval process. Our review found that FRA reviewed and approved incomplete plans that do not fully adhere to FRA regulations. Specifically, we reviewed 102 drug and alcohol testing plans from applicable railroads and determined that approximately 51 percent of the reviewed and approved plans were incomplete and did not contain key elements required by FRA regulations. In addition, FRA's ability to verify and enforce railroads' compliance with drug and alcohol testing requirements is limited by internal control weaknesses. For example, FRA's program guidance for overseeing drug and alcohol testing compliance is outdated and does not reflect current regulations or provide for supervisor review. FRA has also not established a process for following up on action items issued to railroads during compliance audits to verify they undertake recommended actions. Furthermore, FRA procedures do not fully meet its drug and alcohol testing compliance audit goals.Our RecommendationsFRA concurred with all four of our recommendations to improve its guidance and oversight of the drug and alcohol testing program and proposed appropriate actions and completion dates.