Federal Reports

Our objectives were to (1) assess the maturity of National Oceanic and Atmospheric Administration’s (NOAA’s) Polar Follow-On program missions’ system design for indications of cost, schedule or performance issues that would threaten the ability of the Joint Polar Satellite System (JPSS) program to execute to its baselines; (2) determine the extent to which NOAA has complied with requirements to report JPSS development costs; and (3) review NOAA efforts to plan for future satellite technologies.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a complaint that a primary care provider (PCP1) at a Veteran Integrated Service Network (VISN) 20 Facility (Facility) continued to prescribe controlled substances to a patient at high-risk for overdose. The OIG substantiated that PCP1 was aware the patient was getting controlled substances from outside pharmacies and had a history of benzodiazepine abuse, and family members reported that the patient was abusing controlled substances. The OIG substantiated that PCP1 prescribed the patient controlled substances when he was no longer the patient’s designated PCP and despite nonadherence to an Opioid Agreement. The OIG could not substantiate that PCP1 had a reputation among Facility staff of prescribing narcotics “recklessly.” The OIG did not substantiate that providers warned PCP1 about his prescribing practices. The OIG reviewed the Facility’s processes, policies, and procedures about controlled substance prescribing and identified limitations in controlled substance prescribing oversight. The Facility did not have regular processes in place for reviewing controlled substance prescribing for individual patients. The Facility lacked formalized processes and referral mechanisms for interdisciplinary collaboration for patients with complex clinical pain. The Facility had policies for state prescription drug monitoring programs (PDMP) and urine toxicology screens, although no mechanisms to monitor provider responses to positive PDMP and toxicology results. The Facility Board that is responsible for controlled substance safety oversight responsibility for patient record flags was not well defined and lacked established protocols and procedures. The Facility did not comply with the Veterans Health Administration’s peer review directive. The OIG made one recommendation to the VISN Director to review the patient’s care and provider’s practice and seven recommendations to the Facility Director related to prescribing practices and peer review processes.

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a complainant’s allegations regarding an anesthesiologist who provided outpatient sedation services at the James E. Van Zandt VA Medical Center (Facility), Altoona, Pennsylvania. The OIG did not substantiate an allegation that the anesthesiologist failed to follow Veterans Health Administration (VHA) and Facility policies for controlled medication waste because the anesthesiologist documented that the entire amount was used. The OIG did not substantiate an allegation that the anesthesiologist failed to individualize patient medication dosing. The OIG substantiated allegations that the anesthesiologist used more anesthetic/sedation medication for outpatient procedures than Food and Drug Administration approved manufacturer’s instructions recommended, and Facility leaders did not provide oversight of the anesthesiologist according to VHA and Facility privileging and ongoing monitoring policies. The OIG determined that the Facility needs to reevaluate if the provider should be reported to the National Practitioner Data Bank or State Licensing Board for administering medications that were inconsistent with Food and Drug Administration approved manufacturer’s dosage instructions. Additionally, OIG staff determined that the anesthesiologist did not follow Facility policy for pre-procedure documentation for 14 of 20 identified patients and for transfer of a patient who required general anesthesia to a designated VA or non-VA Facility. In reviewing the Facility’s documented patient complaints, OIG staff did not find complaints regarding the anesthesiologist; however, the Facility’s Patient Advocate did not document and track complaints on the Patient Advocate Tracking System as required by VHA. The OIG made four recommendations related to anesthesia needs and services, provider oversight, National Practitioner Data Bank and State Licensing Board reporting, and Patient Advocate Tracking Systems database requirements.