Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to concerns from the U.S. Office of Special Counsel involving a Veterans Integrated Service Network (VISN) 10 medical facility. A complainant alleged an ophthalmologist lacked training, provided substandard care, and failed to meet productivity expectations. Further, despite reported concerns, the Chief of Staff (COS) intended to reappoint the surgeon following the probationary period. The OIG substantiated the surgeon lacked adequate training to perform cataract and laser surgery as the surgeon did not satisfactorily complete an approved residency training program, was ineligible for board certification in ophthalmology, and did not meet the facility’s ophthalmologist hiring requirements. Several credentialing and privileging activities did not comply with Veterans Health Administration requirements and included inadequate primary source verification from foreign educational institutions and insufficient references attesting to the surgeon’s suitability to perform cataract surgeries. The surgeon was hired regardless. Staff concerns about the surgeon’s productivity, competency, and technical skills began within months of hire. The surgeon did not consistently demonstrate the skills to assure good outcomes, was unable to meet surgical productivity expectations, and surgery times exceeded norms. Retrospective clinical reviews by two VISN ophthalmologists reflected deficits. Despite these ongoing concerns, the COS endorsed the surgeon’s reappointment as the facility’s sole ophthalmologist. Multiple system and leadership failures allowed the surgeon to perform cataract surgery and clinic laser procedures without the required training and competency to do so. Once the surgeon’s deficits were identified, facility leaders were slow to respond. As a result, over a two year period, patients were placed at unnecessary risk for potential surgical complications. The surgeon’s employment was subsequently terminated. The OIG made five recommendations related to credentialing and privileging, professional practice evaluations, management of performance deficits, and the actions of the COS.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at the Eastern Oklahoma VA Health Care System. The inspection covers 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 OIG noted that the facility had a newly appointed leadership team supportive of patient safety and quality care but saw opportunities for improvement of employee satisfaction and trust in the leadership. The presence of organizational risk factors, as evidenced by sentinel events, disclosures, and patient safety indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics but should take actions to improve care and performance of selected metrics that are likely contributing to the SAIL “2-star” quality rating. The OIG issued the following 11 recommendations: (1) Medical Staff Privileging • Focused and ongoing professional evaluation processes (2) Environment of Care • Clean/sterile storage (3) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • MST coordinator responsibilities • MST training (4) Geriatric Care: Antidepressant Use among the Elderly • Patient/caregiver education on medications • Medication reconciliation (5) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee core membership • Women Veterans Health Committee reports to the Medical Executive Committee at least quarterly

The Office of the Inspector General audited TVA’s Hydro Generation’s cybersecurity controls. We found TVA had (1) a potential single point of failure that could affect TVA’s ability to operate effectively in the event of a disaster, (2) not configured network devices in a consistent manner, and (3) not maintained updated network documentation. TVA management provided their planned actions to address the recommendations.

Based on the importance of the System Operations Center to the transmission system, we performed an evaluation of the site-selection process to determine if the selected site (1) met regulatory requirements and established criteria and (2) provided financial or operational benefits over other potential locations considered.We determined the site selected for the System Operations Center met established criteria and regulatory requirements. However, we could not determine if the site selected provided financial or operational benefits over other potential locations considered. We identified several issues in the site-selection process, including (1) inaccurate analysis, (2) cost considerations that were high level and not documented, and (3) duplicate parcels. As a result, we determined 4 of the final 6 sites were incorrectly considered for selection by TVA because they did not meet one or more of TVA’s established criteria. Additionally, we identified 1 site that was prematurely eliminated from consideration that should have been included in TVA’s final site selection evaluation.

National Government Services, Inc., claimed unallowable fiscal intermediary and carrier contract Supplemental Executive Retirement Plan costs of $36,524 on its Final Administrative Cost Proposals for fiscal years 2007 through 2013.