Federal Reports

An Amtrak employee in Los Angeles, California, resigned from employment on December 4, 2018, following our investigation which revealed the employee stole money from the Employee Committee Fund. During an interview, the employee admitted to stealing over $20,000 from the fund and using the money to pay for personal expenses. The employee resigned from Amtrak immediately following the interview. Judicial proceedings are pending.

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The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Southern Nevada Healthcare System. The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances Inspection Program; Mental Health: Posttraumatic Stress Disorder; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography; and High-risk Processes: Central Line-Associated Bloodstream Infections. The Facility had generally stable executive leaders who appeared actively engaged with employees. However, opportunities exist to improve patient experiences in the outpatient setting. The OIG reviewed accreditation agency findings, adverse events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results and did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve performance of Quality of Care and Efficiency metrics likely contributing to the current “2-Star” rating. The OIG noted findings in four of the eight areas reviewed and issued eight recommendations attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluation process (2) Environment of Care • Panic alarm testing (3) Medication Management: Controlled Substances Inspection Program • Annual physical security survey • Monthly inspections • Reconciliation process (4) Long-term Care: Geriatric Evaluations • Program evaluation

We performed an evaluation to determine whether demolition and decontamination activities at Widows Creek Fossil Plant (WCF) (1) adhered to safety principles found in the TVA Decommissioning, Deactivation, Decontamination, and Demolition (D4) Program Guide and (2) complied with selected safety criteria established in Brandenburg’s Health and Safety Plan (HASP) for WCF. We determined TVA and Brandenburg met selected safety requirements established in TVA’s D4 Program Guide and Brandenburg’s HASP for WCF. However, during our site visit, we noted safety hazards related to an eyewash station and personal protective equipment that were immediately addressed.