Federal Reports

This review is part of a series of hospital compliance reviews. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2017, Medicare paid hospitals $206 billion, which represents 55 percent of all fee-for-service payments for the year.

This review is part of a series of hospital compliance reviews. Using computer matching, data mining, and data analysis techniques, we identified hospital claims that were at risk for noncompliance with Medicare billing requirements. For calendar year 2017, Medicare paid hospitals $206 billion, which represents 55 percent of all fee-for-service payments for the year.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations that a patient “may have died wrongfully” by aspiration during resuscitation attempts, and that the patient had a Do Not Attempt Resuscitation (DNAR) order but resuscitation was attempted at the Baltimore VA Medical Center (facility), Maryland. The OIG identified concerns related to DNAR documentation and communication, follow-up on a patient safety concern related to medication contraindications, and code blue documentation. The OIG substantiated that the patient died due to aspiration pneumonia, and subsequent cardiopulmonary arrest, and that facility staff attempted resuscitation. The OIG was unable to determine if the cause of death was wrongful. The OIG substantiated that facility staff attempted resuscitation on a patient with a DNAR status; however, there was no DNAR order when resuscitation was attempted. The OIG determined that residents and physicians did not comply with documentation requirements for DNAR orders and DNAR progress notes and failed to effectively communicate the DNAR status to team members. The absence of physician DNAR orders and progress notes, the presence of full code orders in telemetry order sets, and the lack of physician communication regarding DNAR status to the nursing staff resulted in the healthcare team not having the information needed to appropriately intervene when the patient became unresponsive. The OIG found that facility leaders failed to act on an identified pharmacy safety issue related to the administration of haloperidol in patients with Parkinson’s disease. The issue was not addressed until the OIG requested an update in February 2019. The OIG found facility staff did not comply with code blue documentation requirements. The facility’s measures to identify and rectify challenges with resuscitation processes were insufficient. Facility leaders failed to hold clinical staff responsible for code blue documentation. The OIG made four recommendations.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the El Paso VA Health Care System, 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 had been working together for nine months, and the chief of staff and associate director were the newest members of the leadership team and were appointed in April and August 2018, respectively. Selected survey scores related to employee satisfaction with the facility’s leaders and patient experience survey data revealed opportunities to improve both employee and patient satisfaction. The organizational risk factors detailed in this report did not identify any substantial risk in quality of care. The leadership team was knowledgeable within their scope of responsibility about selected SAIL metrics but should continue to take actions to sustain and improve performance measures contributing to the SAIL “1-star.” The OIG issued seven recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Annual inventory of resources and assets • Development and maintenance of an emergency operations plan (3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education and understanding of medications (5) Women’s Health • Women Veterans Health Committee reports to leaders

This report presents the results of the audit of Natural Resources Conservation Service’s (NRCS) financial statements for the fiscal year ending September 30, 2019. The report contains an unmodified opinion on the consolidated financial statements, as well as an assessment of NRCS’ internal controls over financial reporting and compliance with laws and regulations.

Semiannual Report to Congress: Covering April 1, 2019 - September 30, 2019