Federal Reports

We found that inadequate controls resulted in non-compliance with agency policies and guidance from the Office of Management and Budget. To reduce the risk of fraudulent behavior and financial abuse, the agency needs to improve its policies and procedures, training, and oversight provided to the purchase card program. By not maintaining sufficient controls to assure compliance with Peace Corps and Federal requirements, the Peace Corps put itself at risk for fraudulent behavior and financial abuse. We found several weaknesses caused by insufficient controls: inadequate policies and procedures, lack of required training, inadequate oversight, and inadequate use of the available data analytic tools. This report makes six recommendations to help enhance controls over purchase card transactions.

Wisconsin made 1,654 capitation payments totaling $589,478 ($347,822 Federal share) on behalf of deceased beneficiaries. We confirmed that all beneficiaries associated with these capitation payments were deceased.

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The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations concerning the care of a patient who underwent cardiac surgery in 2015 at the VA Ann Arbor Healthcare System in Michigan. The OIG was unable to substantiate that the patient received inappropriate care during cardiac surgery that ultimately led to death. A cardiopulmonary bypass (CPB) catheter that was inserted to divert blood flow from the heart became misplaced. The patient did not receive adequate blood flow to the brain during surgery and died six days later. The OIG was unable to determine how or when the CPB catheter became misplaced. Review of the electronic health record and interviews determined the placement of the catheter, initiation of CPB, and maintenance of CPB during most of the surgery appeared unremarkable. Misplacement of the CPB catheter was discovered towards the end of the procedure, when attempting to restore normal blood flow through the heart. In response to one of the three allegations, the OIG confirmed that the anesthesiologist was present for the critical points of the procedure and did not abandon the patient during surgery. The OIG reviewed the facility’s quality management processes including root cause analysis, peer review, and disclosure records. Not all required processes were completed. Additionally, the facility did not evaluate the modifications that the surgeon and anesthesiologist made in their practices after the patient’s surgery through a systemic quality review to determine if the modifications might be successful or improve patient care. The OIG made one recommendation to the Veterans Integrated Service Network Director related to the facility’s compliance with quality management processes requirements, and one recommendation to the facility Director related to the surgeon’s and anesthesiologist’s modifications in their practice.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations regarding two patients’ care in the Hemodialysis Unit at the Wilmington VA Medical Center in Delaware. Although the OIG was unable to substantiate that the care received in a dialysis unit contributed to a patient’s death, the inspection revealed quality of care issues. The dialysis unit staff did not obtain the patient’s blood glucose level prior to dialysis as ordered and did not follow policy on the urgency required for treating critically high values. Staff failed to clinically assess this patient before release, even though the patient had received non-scheduled medications. Among other concerns, staff administered medication after a verbal, rather than written, order and failed to follow a change to dialysis orders. The patient was found deceased in a car on facility grounds. VA police violated policies and procedures that could have addressed the patient’s car being in an illegal parking spot for more than 17 hours, where the patient was found deceased. The OIG also identified nursing documentation issues, staffing difficulties, and personnel conflicts. Due to unstable nurse management, new policies had not been developed and implemented. Facility leaders and mid-level managers did not assign a Safety Assessment Code or conduct a Root Cause Analysis to look at process or system issues after this patient’s death. The OIG did not substantiate that a nurse incorrectly switched a valve on a machine used for the second patient’s dialysis. The OIG substantiated that dialysis staff initiated CPR on the patient. The patient recovered, but OIG identified concerns related to the emergency response. VA concurred with the 14 recommendations on policy and processes, verbal medication orders, code blue documentation and reporting, and police policy.

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 Captain James A. Lovell Federal Health Care Center (Facility). 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 Care: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The Facility is the only fully integrated VA-DoD medical Facility in the United States addressing the needs and expectations of active duty military, military families, and the local veteran population. The OIG noted that Facility leadership, uniquely shared between VHA and DoD, was actively engaged with employees to improve satisfaction scores. Organizational leadership supported patient safety, quality care, and other positive outcomes. The OIG identified organizational risks related to a lack of consistent risk management, quality management, and/or patient safety processes, including those associated with institutional disclosures, root cause analyses, and peer review activities that may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Director, Chief Medical Executive, and Associate Director for Facility Support. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Physician Utilization Management Advisors’ documentation of decisions • Interdisciplinary review of utilization management data (2) Credentialing and Privileging • Focused Professional Practice Evaluation process (3) Environment of Care • Environmental cleanliness and maintenance (4) Medication Management: Controlled Substances Inspection Program • Annual physical security actions

OIG data analytics identified the Arlington, VA, Main Post Office with two large inventory count discrepancies in the unit reserve stamp stock accountability. The objective of this audit was to determine whether the unit reserve stamp stock inventory was managed effectively at the Arlington, VA, Main Post Office.

OIG data analytics identified the Mesquite, TX, Main Post Office had 104 fuel transactions totaling $9,827 at risk during the period of April through June 2018 and 1,669 Voyager card fuel transactions totaling $55,016 during the April through June 2018 period. The objective was to determine whether Voyager card transactions were properly reconciled for detecting and disputing potentially fraudulent activity at the Mesquite Main Post Office.

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 Oklahoma City Health Care System (Facility). 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 Care: Posttraumatic Stress Disorder Care; Long-term Care: Geriatric Evaluations; Women’s Health: Mammography Results and Follow-Up; and High-Risk Processes: Central Line-Associated Bloodstream Infections. The Facility had generally stable executive leadership since December 2017 and active engagement with employees as evidenced by satisfaction scores. However, opportunities exist to improve patient experiences. Although the OIG noted concern with the number of sentinel events and disclosures, Facility leaders reported reviewing each event, taking corrective actions, and developing preventive measures to improve performance. The OIG reviewed accreditation agency findings, 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 care and performance of selected Quality of Care and Efficiency metrics that are likely contributing to the “3-Star” rating. The OIG noted findings in two of the eight areas of clinical operations reviewed and issued two recommendations that are attributable to the Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Utilization management data review (2) Long-term Care: Geriatric Evaluations • Program oversight and evaluation