Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate the 2016 overdose death of a patient in a residential treatment program (Program) at a Veterans Integrated Service Network 10 medical facility (Facility). The purpose of the inspection was to review the supervision and care of the patient while enrolled in the Program. The OIG identified issues relating to the supervision of the Program patient. Supervision issues involved inconsistent Facility policy directions for patient check-ins, staff compliance with Veterans Health Administration (VHA) and Facility policies/procedures regarding the management of patient check-ins and missing patients when they failed to check-in, and random screening of patients for drugs and alcohol abuse. The OIG identified issues relating to the quality of care of the Program patient. Specifically, the OIG found that Program staff did not develop and implement a timely and comprehensive interdisciplinary treatment plan, provide services during the weekends, reassess the patient’s restrictions, and submit timely and accurate documentation as required by VHA and Facility policies/procedures. The OIG was unable to assess whether the impact of these failures directly affected the patient’s outcome. The OIG made five recommendations to the Facility Director related to the development and implementation of uniform Program policies and a comprehensive interdisciplinary plan, provision of daily services, the reassessment of patient privileges, and accurate electronic health record documentation. The name of the Facility is not being disclosed to protect the privacy rights of the subject of the report pursuant to 38 U.S.C. §7332, Confidentiality of Certain Medical Records, January 3, 2012.

This grant was awarded to the Board to provide funding for the development and deployment of a wireless broadband network to serve Garrett county

This audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The OIG investigated allegations that an official at a tribally controlled college bribed members of the college board of trustees, submitted false mileage claims for work-related travel, retaliated against employees who disagreed with his policies, and failed to report the theft of college funds by a former employee.We did not substantiate the allegations of bribery, false claims, or retaliation. We also found the official ensured the theft was properly reported to law enforcement and that the stolen funds had been repaid in full.The U.S. Attorney’s Office for the District of South Dakota declined to prosecute the former employee for the theft.

Medicare made improper payments of $8.7 million to providers for nonemergency ambulance transports to destinations not covered by Medicare, including the identified ground mileage associated with the transports. Medicare covers ambulance transports to only certain destinations, such as hospitals, skilled nursing facilities (SNFs), and beneficiaries' residences. Medicare also covers these transports from a SNF to the nearest supplier of medically necessary services (diagnostic or therapeutic sites) when the beneficiary is a SNF resident and those services are not available at the SNF. The majority of the improperly billed claim lines (59 percent) were for transports to diagnostic or therapeutic sites, other than a physician's office or a hospital, that did not originate from SNFs. As of the publication of this report, the total improper payment amount of $8.7 million included claim lines outside of the 4-year claim-reopening period.

The objective of the Council of the Inspectors General on Integrity and Efficiency purchase card initiative was to analyze and review Government purchase card data to determine the risks associated with purchase card transactions.

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 San Diego Healthcare 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: 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 OIG also provided crime awareness briefings to 63 employees. The Facility has stable executive leadership. The OIG noted generally satisfied employees; however, opportunities exist to improve inpatient experiences. Organizational leaders supported patient safety, quality of 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 results did not identify any substantial organizational risk factors, but the executive leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the “3-Star” rating. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued five recommendations that are attributable to the Facility Director, Chief of Staff, Associate Director of Patient Care Services, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Ongoing Professional Practice Evaluations (2) Environment of Care • Environment of care rounds attendance • Environmental cleanliness (3) Medication Management: Controlled Substances Inspection Program • Controlled substances reconciliation (4) High-Risk Processes: Central Line-Associated Bloodstream Infections • Staff education