Federal Reports

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the VA Southern Oregon Rehabilitation Center and Clinics, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s leadership team appeared relatively new, having worked together for six weeks, as of the week of the OIG’s visit. Selected survey scores revealed opportunities for the associate director to improve employee satisfaction and provide a safe workplace environment where employees feel comfortable with bringing forth issues or ethical concerns. Opportunities also exist for leaders to improve patient satisfaction. Review of accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to act to improve performance of measures contributing to the SAIL “3-star” quality rating. The OIG issued five recommendations for improvement: (1) Quality, Safety, and Value • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation processes (3) Antidepressant Use among the Elderly • Patient/caregiver education and evaluation of understanding • Medication reconciliation (4) Abnormal Cervical Pathology Results Notification and Follow-up • Patient notification of abnormal results

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the St. Cloud VA Health Care System, covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, 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. Most of the facility’s leadership team had been working together for nearly two years. The acting director, assigned in May 2019, was the newest member of the team; the associate director, the most tenured member, had been in the position since April 2012. Selected employee satisfaction and patient experience survey scores for the facility leaders were generally better than the VHA average. Facility leaders appeared to be actively engaged with patients and supportive of efforts to improve and sustain employee satisfaction. The organizational risk factors detailed in this report did not identify any substantial risk in quality of care. Facility leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning and community living center metrics but should continue to take actions to sustain the Strategic Analytics for Improvement and Learning “5-star rating” and improve performance contributing to the community living center “2-star” rating. The OIG issued four recommendations for improvement in the following areas: (1) Medical Staff Privileging • Ongoing professional practice evaluation processes (2) Mental Health • Military Sexual Trauma provider training (3) Geriatric Care • Patient/caregiver education and evaluation of understanding of newly prescribed medications (4) Women’s Health • Women Veterans Health Committee core membership

The OIG contracted with the independent public accounting firm CliftonLarsonAllen LLP (CLA) to audit VA’s financial statements for the prior two fiscal years: 2019 and 2018. CLA provided an unmodified opinion on VA’s financial statements and identified five material weaknesses concerning controls over significant accounting estimates and transactions; accrued liabilities, undelivered orders, and reconciliations; financial systems and reporting; information technology security; and entity-level controls. The audit also identified instances of noncompliance with laws and regulations, including substantial noncompliance with federal financial management systems’ requirements and the United States Standard General Ledger mandates at the transaction level under the Federal Financial Management Improvement Act. The independent auditors will follow up on these findings in the fiscal year 2020 audit of VA’s financial statements and evaluate the adequacy of corrective actions taken.

Our objective was to assess mail delivery services at the Montbello Station in Denver, CO.

DHS developed a strategy to apply 29 lessons learned from prior system updates to the current Financial Systems Modernization (FSM) TRIO program. Since DHS’ actions provides a positive outlook on the future progress of the FSM TRIO project we made no recommendations for improvement. The report’s limited objective and scope does not provide a complete assessment DHS’ efforts to incorporate lessons learned into their recently reinvigorated FSM efforts.

We found that the CSB was fully compliant with improper payments legislation and guidance during fiscal year 2019.We have amended our previous memorandum dated December 19, 2019, to add a sentence stating that our work was not performed in accordance with generally accepted government auditing standards.