Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Maryland Health Care System, Baltimore, Maryland, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. Executive leadership appeared relatively stable. Employee satisfaction scores were generally better than VHA averages; however, patient experience results identified improvement opportunities. Leaders appeared to support efforts to improve and maintain patient safety, quality care, and positive outcomes. Review of accreditation findings, sentinel events, disclosures, and patient safety indicator data did not identify any substantial organizational risk factors. Leaders were knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance measures contributing to the current SAIL ratings. The OIG issued 23 commendations for improvement: (1) Quality, Safety, and Value • Peer review processes • Interdisciplinary review of utilization management data • Root cause analysis processes • Compliance with life-sustaining treatment orders • Review of resuscitative episodes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Reprivileging processes (3) Environment of Care • Environmental cleanliness • Furniture and equipment condition • Infection prevention and control • Panic alarm installation and testing (4) Medication Management: Controlled Substances Inspections • Monthly controlled substances inspections • Emergency drug cache inspections (5) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • Military sexual trauma training (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Tracking and monitoring cervical cancer data

The Office of the Inspector General conducted a review of the Hydro Dispatch Control Center (HDCC) to identify operational and cultural strengths and risks that could impact HDCC’s organizational effectiveness. Our report identified strengths within HDCC related to (1) organizational alignment, (2) positive interactions within and outside of HDCC, (3) effective leadership, and (4) positive ethical culture. However, we also identified risks that could impact HDCC’s ability to meet its responsibilities in support of Power Operations’ mission. These were comprised of risks including (1) perceptions of lack of effective accountability and (2) execution-related concerns related to inadequate night shift staffing and workspace issues in the System Operations Center.

We contracted with CliftonLarsonAllen LLP (CLA), an independent certified public accounting firm, to perform the audit. This management letter summarizes CLA’s findings and recommendations related to internal control deficiencies and other matters. The issues noted in this report are not significant; therefore, the deficiencies were not required to be reported in the Independent Auditor’s Report Statements (AUD-2020-2/FA-19-137-1). During the FY 2019 audit, CLA did not identified any new internal control deficiencies of less significant matters to be included in this report. CLA, as part of their work, followed up on open recommendations included in the previous years' management letter and closed one recommendation.

As part of our annual audit plan, we audited costs billed to the Tennessee Valley Authority (TVA) by Enercon Services, Inc. (Enercon) for engineering services under Contract No. 7757. The contract provided for TVA to compensate Enercon for work on either a cost reimbursable or fixed price basis. Our audit objectives were to determine if (1) costs were billed in accordance with the terms and conditions of the contract and (2) tasks were issued using the most cost efficient pricing methodology. Our audit scope included about <br> $48.1 million in costs paid by TVA from September 9, 2013, to June 30, 2018.In summary, we determined:Enercon did not provide $94,936 in volume rebates due TVA. In addition, Enercon overbilled TVA $31,792 on cost reimbursable projects, including (1) $24,594 in unsupported travel costs and (2) $7,198 in excessive performance fee payments.The use of fixed price payment terms on a sample of 18 projects totaling $1.34 million caused TVA to pay at least $122,996 (10.11 percent) more than it would have if cost reimbursable payment terms had been used for those projects.We also noted issues with TVA's contract administration, including inadequate oversight of the (1) fee evaluation process and (2) process for evaluating fixed price proposals. Additionally, TVA may have missed the opportunity to receive $22,089 in volume rebates due to a September 2016 contract change with an effective date that benefitted Enercon.(Summary Only)

CFTC’s Compliance with the Digital Accountability and SUBJECT: Transparency Act (DATA Act) of 2014 (FY 2019 Quarter 1) (December 5, 2019)

Management of Select Service Contracts Used by the Office of Data and Technology (ODT) (September 11, 2019)

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the leadership performance and oversight by the Veterans Integrated Service Network (VISN) 4, covering leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; and Medication Management: Controlled Substances Inspections. The OIG conducted this unannounced visit while concurrent inspections of the following VISN 4 facilities were also performed—Coatesville VA Medical Center and VA Butler Healthcare. The VISN’s executive leadership team appeared stable, with the deputy director, chief medical officer, and quality management officer serving together for the past 16 months. Selected survey scores related to employee satisfaction were consistently better than VHA averages. The VISN averages for selected patient experience survey questions were similar to VHA averages. The VISN leaders appeared actively engaged with employees and patients and were working to sustain and further improve satisfaction. The VISN executive leaders seemed to support efforts to improve and maintain quality care. Review of access metrics and clinician vacancies did not identify any substantial organizational risk factors. The VISN leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics and should continue to take actions to sustain and improve performance of measures contributing to the current SAIL ratings. The OIG issued two recommendations for improvement: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Establishment of a VISN emergency management committee

The VA Office of Inspector General (OIG) conducted a rapid response healthcare inspection to review staffing and access concerns at the Mann-Grandstaff VA Medical Center (facility), Spokane, Washington. Seven providers left the facility from early June through mid-July 2019; however, the OIG did not find the loss was unexpected or unusual. The provider losses were due to internal transfers, planned retirements, and resignations. The OIG found that access to some outpatient care started to decline around May 2019. As of August 2019, the percent of primary care new patient appointments completed less than 30 days from the created date decreased from more than 80 percent in April to less than 40 percent in August. The OIG team confirmed that the facility formed a multidisciplinary team to analyze the potential impact on patients, staff, and the facility at large, of closing the intensive care unit due to low utilization. As of late July 2019, the facility was temporarily utilizing one of its two operating rooms. The decision to curtail operating room utilization was the result of Sterile Processing Service staffing shortfalls and other deficiencies identified during a visit from the National Program Office for Sterile Processing (NPOSP). Facility leaders determined that a temporary reduction in operating room procedures and dental services to decrease the volume of items requiring sterile processing was in the best interest of patient safety. A dentist was functioning as the Acting Chief of Radiology. The previous Chief of Radiology voluntarily stepped down to fill a staff radiologist position. The Chief of Dental Service was detailed to the position of Acting Chief of Radiology based on previous leadership experience and qualifications. The OIG made two recommendations related to ensuring that patients have timely access to care and continued corrective actions regarding deficient areas identified in the NPOSP report.