Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Tuscaloosa VA Medical Center, 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 executive leadership team appeared relatively stable; and, upon review of the facility’s accreditation findings, sentinel events, and disclosures, the OIG did not identify any substantial organizational risk. However, the OIG had concerns regarding the root cause analysis process—corrective actions were not implemented or, if implemented, not measured, allowing existing system vulnerabilities that were not eliminated or controlled and exposing veterans to potential and preventable adverse events. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to take actions to improve performance contributing to the SAIL “3-star” and CLC “2-star” quality ratings. The OIG issued 14 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary utilization management data review • Root cause analysis processes (2) Medical Staff Privileging • Ongoing professional practice evaluation process (3) Environment of Care • General safety and cleanliness • Mental health unit panic alarm testing response times • Comprehensive emergency management plan annual review (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST training (5) Antidepressant Use among the Elderly • Medication reconciliation (6) Abnormal Cervical Pathology Results Notification and Follow-up • Assignment of a women’s health medical director • Women Veterans Health Committee core membership • Patient notification of abnormal results

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care at the North Florida/South Georgia Veterans Health System, covering leadership, organizational risks, and key processes associated with promoting quality care. Areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Care; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results; and High-Risk Processes: Emergency Department/Urgent Care Center Operations. The facility’s leadership appeared stable, with four of six positions permanently filled for over one year. Employee satisfaction and patient experience survey were similar to or higher than VHA averages. Leaders supported efforts related to safety and quality care; however, patient safety indicator data, along with missing institutional disclosure information and conflicting survey report information, may contribute to organizational risks. The leaders were knowledgeable about SAIL metrics but should continue to improve care and performance of quality of care metrics contributing to current SAIL ratings. The OIG issued 28 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analyses • Resuscitative episode reviews (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • General cleanliness, maintenance, and biohazardous waste storage • Generator testing (4) Medication Management • Monthly inspections and rotation of inspectors • Verification of orders, drugs held for destruction, prescription pads, hard copy prescriptions, and 72-hour inventories (5) Mental Health • Military Sexual Trauma training (6) Geriatric Care • Patient/caregiver education • Medication reconciliation (7) Women’s Health • Women Veterans Health Committee membership and reporting • Cervical cancer screening data tracking (8) Emergency Departments/Urgent Care Center Operations • On-call social work support • Directional signage (9) Incidental Findings • Medical record scanning backlog • Post Anesthesia Care Unit cardiac monitor inspections and oxygen storage

Our objective was to determine whether the U.S. Postal Service’s Postal Vehicle Service (PVS) Zero Base program was properly implemented and meeting goals. The Postal Service has a PVS fleet and drivers who are career Postal Service employees to move mail between processing facilities, inner-city delivery offices, and local businesses and mailers. PVS is primarily used for distances within a 50-mile radius of their Postal Service location.

NDF did not always claim and account for HHS grant funds in accordance with Federal requirements. We identified unallowable claims for indirect costs totaling $142,104. We also identified other costs totaling $15,618 that did not fully meet Federal requirements but were related to the purpose of the grant. These costs included $9,968 for contractual services and $5,650 for cost transfers. In addition, NDF's financial management system was not in compliance with Federal regulations. NDF claimed unallowable costs because it did not always follow its policies and procedures for claiming and accounting for HHS grant funds.