Federal Reports

The Improving Head Start for School Readiness Act of 2007 required the U.S. Department of Health and Human Services, Administration for Children and Families (ACF), Office of Head Start (OHS), to develop the Designation Renewal System to ensure that it would not automatically renew a Head Start grant for a grantee that has not provided a high-quality and comprehensive Head Start program. Instead, the Head Start grant would be subject to an open competition. In 2013, OHS notified Pathways for Children, Inc. (Pathways) that because of noncompliance with program requirements, it would be required to compete for Head Start funding. Pathways applied to compete for the Head Start funding and was awarded the grant again as the sole applicant. On the basis of its noncompliance, we selected Pathways for this audit.

We reviewed the oversight of opioid prescribing and the monitoring of opioid use in Alabama. This factsheet shows Alabama's responses to our questionnaire covering five categories related to its approach to addressing the opioid epidemic: policies and procedures, data analytics, programs, outreach, and other efforts.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Northern Arizona VA Health Care System, covering leadership, 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; and 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 leaders were relatively new to their positions. Reviewing the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risk factors. However, patient experience survey data revealed opportunities for improvement in the Patient-Centered Medical Home outpatient setting. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should continue to take actions to improve performance of measures contributing to the facility’s SAIL “2-star” quality rating. The OIG issued 20 recommendations for improvement: (1) Quality, Safety, and Value • Utilization management processes • Root cause analyses actions • Analyses of resuscitation episodes (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • Medication safety (4) Controlled Substances Inspections • Reconciliation for return of stock • Emergency drug cache inspection (5) Military Sexual Trauma Follow-up and Staff Training • MST Coordinator responsibilities • Providers’ training (6) Antidepressant Use among the Elderly • Patient/caregiver education • Medication reconciliation (7) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee requirements • Tracking cervical cancer screening data • Communicating abnormal results to patients (8) Emergency Departments and Urgent Care Center Operations • Backup call schedules for emergency department providers and social workers (9) Incidental Finding • Concentrated opioids storage safety

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This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the VA Pacific Islands Health Care System, covering leadership, 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; and Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up. The facility’s leaders were all permanently assigned. The OIG noted that opportunities exist for the associate director for Patient Care Services to improve nursing staff satisfaction and attitudes. The leaders appeared to support efforts to improve and maintain patient safety, quality care, and other positive outcomes. The OIG’s review of the facility’s accreditation findings, sentinel events, and disclosures did not identify any substantial organizational risk factors. The leaders were knowledgeable within their scope of responsibility about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to improve performance of measures contributing to the facility’s SAIL and CLC “2-star” quality ratings. The OIG issued 12 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • Medication safety, infection prevention, and patient privacy processes at the parent facility • Environmental cleanliness and protection of patient information at the Leeward Oahu VA Clinic (4) Controlled Substances Inspections • Verification of controlled substances orders (5) Military Sexual Trauma Follow-up and Staff Training • Military sexual trauma mandatory training (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership • Cervical cancer screening data tracking • Communicating abnormal results to patients

Audit of the the NLRB IT security for the FY 2019 FISMA submission.