Federal Reports

The VA Office of Inspector General (OIG) identified a primary care provider who appeared to have falsely documented patients’ blood pressure readings at the Danville Community Based Outpatient Clinic (CBOC) of the Salem VA Medical Center (facility), Virginia. The CBOC is a contracted clinic staffed and operated by Valor Healthcare, Inc. In a preliminary review, OIG inspectors identified that the provider repeatedly documented blood pressure rechecks of 139/89. The OIG immediately notified the facility’s Chief of Staff (COS) and recommended a comprehensive analysis be done to evaluate the extent of the 139/89 entries. In an expanded review, the OIG determined the provider had not only falsified repeat blood pressure readings (readings higher than 139/89 would have required additional follow-up), but also failed to provide hypertension management to patients with initially elevated blood pressure readings. An OIG physician found limited evidence of interventions, treatment plan adjustments, medication changes, or close follow-up. Further, the OIG found the COS’s initial response to be troubling. Despite being told of the concerns, it was not until the OIG team contacted the COS eight weeks later that the facility began an in-depth review of the provider’s documentation practices and management of patients with hypertension. Multiple factors allowed the provider’s falsification of blood pressure readings to continue unabated, including lack of facility processes to validate the accuracy of performance measure data impacting monitoring reports. In addition, • None of the Valor Healthcare employees with knowledge of the falsified blood pressure documentation shared their concerns with staff positioned to take corrective action, and • Neither the facility nor Valor Healthcare were meeting aspects of the contract. The OIG made five recommendations related to patient care follow-up, data integrity, policy and procedure development, leadership responsiveness, and contract-related training.

The Office of the Inspector General audited TVA’s internal controls in place to prevent, detect, and report unauthorized access and disclosure of human resource (HR) system Personally Identifiable Information (PII). We found TVA has weaknesses in its internal controls to prevent and detect unauthorized access and disclosure of HR system PII. TVA management agreed with our recommendations for improving the internal controls.

U.S. Immigration and Customs Enforcement (ICE) contracts with 106 detention facilities to detain removable aliens. In FY 2017, these 106 facilities held an average daily population of more than 25,000 detainees. Since the beginning of FY 2016, ICE has paid more than $3 billion to the contractors operating these 106 facilities. Despite documentation of thousands of deficiencies and instances of serious harm to detainees that occurred at these detention facilities, ICE rarely imposed financial penalties. ICE should ensure that detention contracts include terms that permit ICE to hold contractors to performance standards and impose penalties when those standards are not maintained.