Federal Reports

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Oscar G. Johnson VA Medical Center. The inspection covers leadership and organizational risks and key clinical and administrative processes associated with promoting quality care. At the time of the review, the areas of focus were Quality, Safety, and Value (QSV); Medical Staff Privileging (MSP); Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma (MST) 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: Urgent Care Center (UCC) Operations. The facility’s executive leadership team appeared relatively stable and seemed to be actively engaged with employees and patients. The leaders were also working to sustain employee and patient engagement and satisfaction which were above VHA averages and appeared to support efforts to continually improve and maintain positive outcomes, patient safety, and quality care. Review of the facility’s accreditation findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “5-star” and CLC “3-star” quality ratings, respectively. The OIG issued nine recommendations for improvement in the following areas: (1) QSV • Peer review improvement actions • Interdisciplinary review of utilization management data (2) MSP • Focused professional practice evaluation for cause process (3) Mental Health • MST initial evaluations (4) Geriatric Care • Patient/caregiver education on medications • Medication reconciliation (5) Women’s Health • Women Veterans Health Committee core membership (6) High-Risk Processes • Urgent care center registered nurse staffing • Backup call provider schedule

The thirteen reports that DHS OIG retracted and removed from its website were not compliant with applicable standards. The deficiencies in the retracted reports were a result of several key changes to DHS OIG’s approach to oversight work that were poorly communicated and managed by senior leaders, a flawed report model and internal control failures, including the areas of audit planning, supervision, and independent referencing. This combination of factors led DHS OIG to publish thirteen reports concluding that FEMA’s initial response to certain declared disasters was efficient and/or effective despite lacing sufficient and appropriate evidence to support that conclusion. DHS OIG concurred with the five recommendations made.

Under the home health prospective payment system (PPS), the Centers for Medicare & Medicaid Services pays home health agencies (HHAs) a standardized payment for each 60-day episode of care that a beneficiary receives. The PPS payment covers intermittent skilled nursing and home health aide visits, therapy (physical, occupational, and speech-language pathology), medical social services, and medical supplies.

Semiannual Report to Congress: Covering October 1, 2018 - March 31, 2019

We determined that DHS did not comply with Improper Payments Elimination and Recovery Act of 2010 (IPERA) because it did not meet two of the six requirements. Specifically, the Department omitted the percent of recaptured amounts from the Other Information section in its Agency Financial Report and did not meet its annual reduction target established for one of eight programs deemed susceptible to significant improper payments. DHS also did not comply with Executive Order 13520, Reducing Improper Payments, because it did not make available to the public DHS’ Quarterly High-Dollar Overpayment report for the second quarter of FY 2018. In addition, the third-quarter report DHS posted on its website erroneously excluded information on actions the agency has taken to recover high-dollar overpayments. Additionally, we reviewed DHS’ processes and procedures for estimating its annual improper payment rates. Based on our review, we determined that DHS did not provide adequate oversight of the components’ improper payment testing and reporting. We made seven recommendations to DHS’ Risk Management and Assurance Division to follow the Office of Management and Budget’s requirements to comply with IPERA, and to strengthen its oversight and review procedures for IPERA risk assessments.