Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Roseburg VA Health Care System (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The Facility has been and continues to be in transition. Three of the four executive leaders were new to their positions, and two were in temporary assignments. Facility challenges including ineffective leadership, toxic culture, personnel practices, and improper admission practices have been reported by media and were the subject of recent internal and external evaluations. The OIG reviewed accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors. However, the OIG identified concerns with hydromorphone (pain medication) shortages, gaps in provider privileging processes, and inadequate tracking and monitoring of On-demand supplies. The senior leadership team appeared aware of the magnitude of the challenges and were taking action to restore a culture of trust, increase employee and patient satisfaction, and improve the quality of care and efficiency metrics contributing to the “1-Star” rating. The OIG noted findings in three of the seven areas of clinical operations reviewed and issued seven recommendations that are attributable to the Interim Director, Acting Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations processes (2) Environment of Care • Storage of cleaning solutions in food preparation areas (3) Medication Management: CS Inspection Program • CS monthly inspections • CS reconciliation

TFC Consulting, Inc. (TFC), an independent licensed Certified Public Accounting firm, was contracted by the Department of Agriculture (USDA), Office of Inspector General (OIG) to conduct an agreed-upon procedures engagement at Louisiana and provide the Food and Nutrition Service (FNS) with recommendations to enhance program efficiency and effectiveness.

The National Institute of Transplantation (NIT), an independent histocompatibility laboratory located in Los Angeles, California, did not fully comply with Medicare requirements for reporting tissue-typing costs and revenues on its fiscal year (FY) 2012 Medicare cost report. Of the 186 cost transactions that we reviewed, 177 were correctly reported; however, the remaining 9 transactions, totaling $81,063, were incorrectly reported. Of the 751 tissue-typing tests that we reviewed, 711 were correctly reported; however, the remaining 40 tests and 94 additional tests, with combined revenues totaling $50,000, were incorrectly reported.

The objective of this Management Advisory Report was to determine the agency's rationale for maintaining a full staff at the Peace Corps/Kenya post following its suspension in July 2014 and to determine if resources were unnecessarily expended to operate the fully-staffed post for almost 3 years after the suspension. Our results demonstrate that the agency did not deliberately and effectively assess necessary staffing levels throughout the suspension of Peace Corps/Kenya, does not have dedicated policies or procedures governing post suspensions, and did not maintain adequate documentation of key decisions concerning the suspension. This report contains two recommendations.

This grant funds to provide support for the Partnership for Regional Economic Performance (PREP) program which is designed to provide economic development in the greater North Central PA area.

The Commission is a public, non-profit corporation established in 1967 under the PA non-profit Corporation law.