Federal Reports

Gladys Perez, Coach Cleaner, Los Angeles, California, was terminated from employment on December 5, 2019, following an administrative hearing for violating company policy. Our investigation found that Perez participated in a health care fraud scheme in which Amtrak’s health care plan was billed for acupuncture and other services that were not actually provided. On October 10, 2019, Perez signed a pretrial diversion letter agreement, which was accepted in U.S. District Court for the Central District of California, wherein she admitted to committing two counts of health care fraud in furtherance of the scheme to defraud the company’s health plan.

This review provides a focused evaluation of the quality of care delivered at the Coatesville VA Medical Center, covering leadership and organizational risks and key 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. The executive leadership team appeared stable and engaged as they worked to sustain and improve employee and patient engagement and satisfaction. Review of accreditation organizational findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. However, the Executive Leadership Board was not following actions until completion. The leaders were aware of Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to maintain and improve performance contributing to the SAIL “5-star” and CLC “2-star” quality ratings. The OIG issued 16 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Implementation of corrective actions from root cause analyses (2) Medical Staff Privileging • Medical Executive Board review/recommendation of privileging actions (3) Environment of Care • Environmental cleanliness • Inventory of resources and assets for emergency management • Generator testing (4) Controlled Substances Inspections • Inspector appointments and competencies • Verification of controlled substance orders (5) Mental Health • Military sexual trauma training (6) Geriatric Care • Patient/caregiver understanding of medication education (7) Women’s Health • Women Veterans Health Committee membership (8) Emergency Departments and Urgent Care Centers (UCC) • Waiver for 24-hour operations • Registered nurse staffing • Availability of support services (9) Incidental Finding • Ambulance transportation of emergent patients to UCC

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Chalmers P. Wylie Ambulatory Care Center 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. The facility’s executive leadership had been working together for about nine months. Employee satisfaction and patient experience scores were similar to or better than the VHA average. Organizational leaders appeared to support efforts related to safety and quality care; however, there were concerns related to wrong-site /wrong-procedures and appropriate and timely institutional disclosures. The leaders were knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance of measures contributing to the current SAIL ratings. The OIG issued 13 recommendations for improvement in the following areas: (1) Quality, Safety, and Value • Implementation of peer review improvement actions • Completion of Root Cause Analyses • Committee review of resuscitative episodes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes • Medical Executive Board consideration of OPPEs in recommendation to continue privileges (3) Controlled Substances Inspections • Quarterly review of controlled substances inspections reports (4) Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Abnormal results notification (7) Incidental • Anesthesia documentation of controlled substance administration

What We Looked AtThe Federal Aviation Administration's (FAA) Next Generation Air Transportation System (NextGen) is a multibillion-dollar transportation infrastructure project that requires airspace users to purchase and install new avionics on their aircraft. This includes Automatic Dependent Surveillance-Broadcast (ADS-B) Out, which FAA has mandated all operators who intend on flying in most controlled domestic airspace install by January 1, 2020. Citing concerns about whether operators will meet the 2020 deadline, the then-Chairmen of the House Committee on Transportation and Infrastructure and its Aviation Subcommittee requested that we provide information regarding equipage rates for ADS-B and other NextGen technologies on air carrier and general aviation aircraft. Accordingly, our audit objectives were to (1) determine the equipage rates for ADS-B and other NextGen-enabling technologies on commercial and general aviation aircraft, (2) ascertain the reasons behind aircraft operators' decisions to equip or not equip with these technologies, and (3) assess FAA and aircraft operators' plans to meet the 2020 ADS-B Out equipage deadline.What We FoundWe found that ADS-B Out equipage rates are increasing as the 2020 deadline approaches with other equipage rates varying depending on the NextGen technology. In addition, operators are installing ADS-B Out primarily due to the mandate but also consider financial and operational factors when equipping with NextGen technologies, such as potential benefits. Finally, most commercial and turbine-powered general aviation operators who will fly in ADS-B Out airspace plan on meeting the 2020 deadline. However, FAA has not finalized procedures needed by non-equipped operators to access ADS-B Out airspace.Our RecommendationsWe made three recommendations to FAA concerning having the necessary systems and procedures in place so operators can access ADS-B Out required airspace. FAA concurred with two of our recommendations and provided appropriate planned actions and completion dates. It did not concur with one recommendation to analyze the feasibility of developing automated systems to provide operators with more timely information regarding GPS outages or degradation. The Agency concluded that developing these additional systems is redundant and an inefficient use of resources. Based on its response, we believe that FAA has assessed the feasibility of developing automated systems as noted in recommendation 2. We consider this recommendation closed.

In recent years, IHS has had a number of cases of healthcare providers abusing patients under facility care, including a pediatrician who was convicted of multiple counts of child sexual abuse. In February 2019, the Deputy Secretary of the Department of Health and Human Services requested that OIG assess IHS policies and procedures for preventing, reporting, and addressing patient abuse.

We performed an audit of costs billed to the Tennessee Valley Authority (TVA) by a company for the supply of natural gas to TVA's combined cycle or combustion turbine generation plants. Our audit included approximately $205 million in costs billed to TVA for gas delivered from June 1, 2017, to May 31, 2019. Our audit objectives were to determine if (1) the costs billed to TVA were in accordance with the contract's terms and conditions, (2) TVA's analysis to support current contract pricing was reasonable, and (3) the contract's current pricing methodology is reasonable for a potential extension when the pricing agreement expires.In summary, we determined the company billed TVA in accordance with the contract terms. In addition, we determined the analysis and assumptions used by TVA in entering into an agreement with the company to purchase 75,000 dekatherms per day of natural gas from April 1, 2017, through March 31, 2021, were reasonable and resulted in significant discounts and savings to TVA. Furthermore, we determined the contract's current pricing methodology is reasonable for a planned 3-year extension, and, if TVA is able to negotiate similar contract pricing, we estimated it could save about $849,000 compared to estimated future market prices. (Summary Only)