Federal Reports

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 Veterans Health Care System of the Ozarks (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 OIG also provided crime awareness briefings to 125 employees. Although two of the Facility’s four executive leaders were in interim positions during the OIG’s on-site visit, the leaders had worked to support efforts related to patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. Although the leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Access metrics that are likely contributing to the “4-Star” rating. The OIG noted findings in five of the eight areas of clinical operations reviewed and issued six recommendations that are attributable to the Facility Director, Chief of Staff, and Interim Associate Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Interdisciplinary review of UM data (2) Credentialing and Privileging • Ongoing Professional Practice Evaluation process (3) Environment of Care • Environment of Care rounds participation (4) Medication Management: Controlled Substances Inspection Program • CS Coordinator position description • Controlled substances order verification (5) Women’s Health: Mammography Results and Follow-Up • Linkage of mammography results to radiology order

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Northport VA Medical Center (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Credentialing and Privileging; Environment of Care (EOC); Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Post-Traumatic 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 current Director and the Associate Director were permanently assigned in June 2017. The former Chief of Staff and Associate Director for Patient Care Services were assigned to positions outside the Facility in August 2017, and the positions have since been filled by interim appointees. Further, opportunities appear to exist for the Director and Associate Director to provide a workplace environment where employees feel safe to bring forth issues or ethical concerns. The lack of consistent leadership oversight of quality improvement activities may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and monitored. The OIG noted findings in five of the clinical operations reviewed and issued 11 recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) QSV • Interdisciplinary utilization management data reviews • Implementation of root cause analysis actions and provision of feedback • Facility Leaders’ review of annual patient safety report (2) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluation processes (3) EOC • EOC rounds frequency • Pest management program • Safe and clean environment • Medical equipment safety inspection process • Mental Health seclusion room safety (4) Medication Management: CS Inspection Program • Electronic access for performing and monitoring CS balance adjustments (5) Long-Term Care: Geriatric Evaluations • Performance improvement oversight

The OIG’s data analysis identified Raleigh, NC, Capitol Station had local purchases totaling $8,240, or 27 percent of all local purchases in the Greensboro District, for the period January 1 through March 31, 2018. It is unusual for one office to have such a high percentage of local purchases as it relates to other offices in the same district. The objective was to determine whether local purchases and payments were valid and properly supported at the Raleigh, NC, Capitol Station.

We reviewed eight recommendations (Recommendations 1 and 3 – 9) presented in our August 2015 audit report U.S. Department of the Interior’s Climate Science Centers, to verify that the U.S. Geological Survey has implemented them.We confirmed that all eight recommendations have been resolved and implemented.

We reviewed documentation provided to support the closure of a recommendation from a 2007 audit of the U.S. Department of the Interior’s use of cooperative agreements.Based on our review, we do not agree that the recommendation is resolved and implemented. We have requested that the Office of Financial Management reinstate the recommendation and take appropriate follow-up action for resolution.

We audited the costs claimed by the Missouri State Department of Conservation under grants awarded by the U.S. Fish and Wildlife Service (FWS) through the Wildlife and Sport Fish Restoration Program. The audit included claims totaling approximately $68.3 million on 39 grants that were open during the State fiscal years that ended June 30, 2014, and June 30, 2015. The audit also covered the Department’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using hunting and fishing license revenue and reporting program income.We questioned costs totaling $2,813,979 due to financial management system errors, improper drawdowns, unreported program income, unsupported subaward claims, and unallowable indirect costs. In addition, we determined that the Department potentially diverted $30,500 in license revenue in a real property trade and did not comply with Federal and State subaward requirements.The FWS agreed with our 16 recommendations, and it will work with the Department to implement corrective actions.

We audited costs claimed by the State of Michigan, Department of Natural Resources (Department), under grants awarded by the U.S. Fish and Wildlife Service (FWS) Wildlife and Sport Fish Restoration Program. Our audit included claims totaling $91 million on 25 grants that were open during the State fiscal years that ended September 30, 2014, and September 30, 2015. The audit also covered the Department’s compliance with applicable laws, regulations, and FWS guidelines, including those related to collecting and using hunting and fishing license revenues, and reporting program income. We questioned costs totaling $60,306,048 related to unsupported payroll and in-kind match and unallowable in-kind contributions and other costs. In addition, we found that the Department: 1) potentially diverted real property acquired with license revenue, 2) had not adequately managed equipment, and 3) had not provided sufficient oversight of subawards.The Department and the FWS provided responses to our draft report. Based on these responses, we consider 1 recommendation resolved and implemented, 10 recommendations resolved but not implemented, and 3 recommendations unresolved.

We focused our audit on the drawdowns made by the National Academy of Sciences (NAS) on Cooperative Agreement No. S16AC20034 with the Office of Surface Mining Reclamation and Enforcement (OSMRE) between September 26, 2016, and December 6, 2017.Our audit focused on whether the costs claimed by the National Academy of Sciences were allowable, allocable, and reasonable according to applicable Federal laws and regulations and OSMRE guidelines. We did not identify any issues with the costs claimed.