Federal Reports

The review was performed to determine whether the Department made purchase card transactions that were potentially illegal, improper, or erroneous. We performed this review in conjunction with a government-wide project initiated by the Council of the Inspectors General on Integrity and Efficiency (CIGIE), Information Technology (IT) Committee, to determine risks associated with government purchase card transactions. We found no instances of purchase card transactions that appeared to be illegal, improper, or erroneous for the transactions included in our review. However, we did identify areas where the Department could improve its internal controls over purchase card use. Specifically, we found instances where purchase cardholders did not always follow Department policy, to include obtaining or maintaining adequate documentation to support purchases. As a result, there is greater likelihood that cardholders may make inappropriate purchases, potentially resulting in an increased risk of fraud and misuse of funds

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations regarding patient safety and poor quality of care in the Haley’s Cove Community Living Center (CLC) at the James A. Haley Veterans Hospital (facility) in Tampa, FL. The OIG substantiated that with Resident A’s 2016 fall, CLC staff had not implemented fall precautions and the Emergency Department physician did not adequately evaluate his injuries. The OIG found Resident A’s injuries to be consistent with those experienced in a fall. The OIG did not substantiate that staff failed to properly notify the family after Resident A’s fall or that staff improperly kept him on a gurney. The OIG substantiated CLC staff used a smaller-sized urinary catheter on Resident A, but found no evidence that this negatively impacted him. The OIG determined that medication changes/adjustments were reasonable and that family consent was not required. Further, the nurse practitioner’s decision not to order a urinalysis was appropriate. The OIG found CLC staff did not implement Resident B’s fall precautions. Resident B fell in early 2017 and died 9 days later. From October 1, 2016 through March 31, 2017, the facility’s CLC exceeded VHA-wide rates for falls with major injuries. The OIG inspected 46 CLC residents’ rooms and found that CLC staff did not consistently implement fall precautions. The facility did not adequately review and follow up with Resident C’s 2015 allegations of abuse, but did review and follow up with Resident D’s and Resident E’s allegations of neglect and “rough” handling. The OIG did not substantiate family members’ concerns about possible retaliation from staff if they complained about care. On 2 selected days in February 2017, the OIG found CLC units met minimum staffing levels but not the registered nurse staffing mix recommendation. During OIG's unannounced visit, we found CLC units to be clean, odor free, and well-maintained. The OIG made six recommendations.

In November 2015, we reported that the Federal Emergency Management Agency’s (FEMA) information technology (IT) management approach did not adequately address technology planning, governance, and system support challenges to effectively support its mission. We issued five recommendations to the FEMA Chief Information Officer (CIO) aimed at improving the agency’s management of IT.1 Specifically, we recommended the CIO finalize key planning documents related to IT modernization; execute against those planning documents; fully implement an IT governance board; improve integration and functionality of existing systems; and implement agency-wide acquisition, development, and operation and maintenance standards.

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 Jonathan M. Wainwright Memorial VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value (QSV); Medication Management: Anticoagulation Therapy; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; Long-Term Care: Community Nursing Home (CNH) Oversight; and Mental Health Residential Rehabilitation Treatment Program. The OIG also provided crime awareness briefings to 92 employees. Due to past leadership and organizational failures, the facility and its leaders are in a state of transition and face a challenging task of improving the organizational culture. The leaders spoke enthusiastically of ongoing efforts to rebuild workforce and patient trust and engagement, boost employee and patient satisfaction, achieve leadership stability, and improve organizational performance. These actions included actively engaging with and involving employees at all levels and developing an infrastructure with key personnel that will support and sustain organizational transformation. The OIG noted findings in four areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director for Patient Care Services, and Associate Director. The identified areas with deficiencies are: (1) QSV • Senior-level committee for QSV functions • Annual completion of required root cause analyses (2) Medication Management: Anticoagulation Therapy • Analysis and reporting of quality assurance data • Patient education specific for newly prescribed anticoagulant medications • Laboratory tests completion prior to initiating anticoagulant medications • Staff competency assessments (3) EOC • Frequency of and participation in EOC rounds (4) Long-Term Care: CNH Oversight • Multi-disciplinary participation in Oversight Committee • Cyclical clinical visits