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 Cincinnati VA Medical Center (the 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 111 employees. The Facility has generally stable executive leaders who were actively engaged with employees and patients and supported patient safety and quality care. 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. The senior leadership team was knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the “4-Star” ranking. The OIG noted findings in four of the eight areas of clinical operations reviewed and issued seven recommendations that are attributable to the Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: 1) Quality, Safety, and Value • Documentation of patient safety events into the Patient Safety Information System 2) Credentialing and Privileging • Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation processes 3) Environment of Care • Attendance on environment of care rounds • Contamination prevention in equipment storage shelves 4) Medication Management: Controlled Substances Inspection Program • Controlled substances coordinator (CSC) duties included in Alternate CSC position description • Same-day completion of physical inventories of the controlled substances storage areas

At the request of Senator Sherrod Brown, the VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection on clinical and administrative concerns at the Cincinnati VA Medical Center (facility), Ohio, that had been cited previously in reports by the OIG or the Veterans Health Administration’s Office of the Medical Inspector. The storage areas that the OIG team inspected were generally clean, with clean and dirty materials stored separately. Although the facility did not have a written policy or procedure for reporting reusable medical equipment reprocessing errors, an appropriate process, including an electronic tracking system, was in place. At the time of the OIG’s site visit in October 2017, the facility had adequately addressed these issues. The facility’s Methicillin-resistant Staphylococcus aureus (MRSA) surveillance and prevention activities appeared to be improving as the facility did not report new infections during the second half of fiscal year 2017. As of late January 2018, the facility was taking reasonable actions to prevent new MRSA infections. The facility has reportedly had difficulty recruiting and retaining Intensive Care Unit nurses because it is unable to meet salaries offered by other healthcare organizations. As of early February 2018, the facility was taking reasonable steps to ensure patient care and safety when Intensive Care Unit nurse staffing was not optimal, and to improve nurse recruitment and retention through pay parity efforts. The OIG made no recommendations.

We investigated allegations that a former National Park Service (NPS) senior official at Acadia National Park (ACAD), Bar Harbor, ME, violated Federal criminal laws prior to his retirement and through his post-employment work with a nonprofit organization that receives Federal funds through a cooperative agreement with the park. We also investigated an allegation that the senior official participated in improper fundraising activities during a retirement dinner sponsored for him by the nonprofit organization.We found that the subject of our investigation, while still an NPS senior official, illegally accepted $14,771 in gifts from the nonprofit organization and its board members. We also found that he negotiated for employment with the organization while he was a Government employee and while participating in matters that affected the organization, a violation of Federal criminal law. He further violated Federal criminal law when he communicated with the Government on behalf of the organization following his retirement regarding particular matters that he had worked on while an NPS senior official.We found that the former senior official’s participation in the retirement dinner did not violate Federal fundraising rules. While at the dinner, however, he violated ethics regulations by accepting gifts from outside sources.We presented our findings to the U.S. Attorney’s Office for the District of Maine and the Department of Justice, Public Integrity Section, which declined prosecution.We are providing this report to the NPS Deputy Director for any action deemed appropriate.

The Postal Service has service standards (timeliness goals) for delivering FCM after receiving it from a customer. A service standard represents the level of service the Postal Service attempts to provide to its customers. The service standard is determined by which geographic location mail originates from (comes from) and to which geographic location mail is destined (goes to). A mailpiece’s combined origin and destination is known as a service pair and examining these pairs allows the Postal Service to evaluate service performance based on the mail’s origin, destination and a combination of both. Our objective was to evaluate the U.S. Postal Service’s strategy to improve First-Class Mail (FCM) service performance scores in the Northeast Area.

The Centers for Medicare & Medicaid Services (CMS) did not always provide accurate Medicaid unit rebate offset amounts (UROAs) to State Medicaid agencies (State agencies) during the period January 1, 2010, through December 31, 2014, in accordance with Federal guidance. (Under the Medicaid drug rebate program, drug manufacturers enter into rebate agreements with the Federal Government and pay rebates to States. Amounts collected by the States that are attributable to increased rebates mandated by recent legislation—UROAs—are applied against the amounts that the Federal Government pays to the States.)