Federal Reports

The objective of our audit was to evaluate the effectiveness of the U.S. Postal Service’s maintenance optimization initiative in the Northeast Area. Headquarters management established and tracked maintenance optimization planned savings at the national level only and not at the seven Postal Service areas. To determine area performance, we obtained FY 2017 actual versus plan workhours for LDCs 37 and 38, respectively.

The former Chairman of the U.S. House of Representatives, Committee on Veterans’ Affairs requested the OIG investigate allegations of widespread equipment mismanagement at the research laboratories of the Eastern Colorado Health Care System (ECHCS) in Denver, Colorado. The OIG substantiated the wide range of allegations about ECHCS Logistics and Research Services’ mismanagement of research equipment, materials, specimens, and that its research facilities, chemicals, and Personally Identifiable Information were inadequately secured. The identified issues occurred because the ECHCS Chief Logistics Officer and Research Service Administrative Officer did not ensure their staff consistently complied with VA policies, procedures, and guidance related to management and accountability of equipment. Until controls are in place to ensure staff follow applicable equipment management policies, the risk that equipment will be mismanaged continues to exist. The OIG was also asked to determine the amount of money wasted because of any mismanagement, the identity of responsible officials, corrective actions taken to address the underlying causes of any mismanagement, and to evaluate the appropriateness of certain equipment transfers to the University of Colorado (UC) research facilities. The OIG could not determine a precise amount of money wasted on equipment due to mismanagement by VA staff, as the majority of the equipment sampled was near the end of or beyond its useful life span and likely had little to no residual monetary value. The OIG concluded that while the equipment users and the ECHCS Medical Center Director are required to properly manage equipment, the ECHCS Research Administrative Officer and the Chief Logistics Officer said management of research equipment was one of their primary responsibilities. The OIG noted the ECHCS Medical Center Director implemented an action plan that included processing the existing unrequired and abandoned equipment. The OIG did not identify anything inappropriate with the transfer of VA research equipment to UC. The OIG recommended ECHCS improve equipment accountability controls, materials and specimen monitoring, and facility security.

The VA Office of Inspector General Administrative Investigations Division issued a report titled: Administrative Investigation of Conflict of Interest, Nepotism, and False Statements within the VA Office of General Counsel, Washington, DC.

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 North Texas Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value; Environment of Care (EOC); Medication Management: Controlled Substances (CS) 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 210 employees. The facility’s leadership team is relatively new. The OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. However, the OIG noted that the facility needed to establish a more accurate and reliable system for managing institutional disclosures. The OIG’s review of survey data suggested generally satisfied employees; however, opportunities exist to improve patient experiences. The leadership team was knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) metrics, and improvements demonstrated leadership’s continued commitment and efforts to improve care and performance of selected quality and efficiency metrics. The OIG noted findings in four of the clinical operations reviewed and issued six recommendations that are attributable to the Facility Director, Chief of Staff, and Nurse Executive. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused Professional Practice Evaluations include clearly delineated timeframes, criteria, and review of privilege-specific criteria • Ongoing Professional Practice Evaluations include the use and review of service- and practitioner-specific data (2) EOC • Availability of personal protective equipment (3) Medication Management: CS Inspection Program • Reconciliations of CS refills and returns to pharmacy (4) Women’s Health: Mammography Results and Follow-Up • Communication of results to patients

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Samuel S. Stratton VA Medical Center (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value (QSV); Environment of Care (EOC); Medication Management: Controlled Substances (CS) 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 64 employees. Facility leaders were actively engaged with employees and patients and were working to improve employee satisfaction scores (such as initiating processes and plans to maintain positive perceptions of the facility). Organizational leadership appears to support patient safety and quality care. However, the OIG is concerned with the number of sentinel events, institutional disclosures, and post-operative/post-procedural adverse events. Although the senior leadership team was knowledgeable about selected SAIL metrics, the 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 five areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Interim Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Use of Ongoing Professional Practice Evaluation results for reprivileging (2) QSV • Documentation of decisions by physician utilization management (UM) advisors • Interdisciplinary group review of UM data • Feedback about root cause analysis actions (3) EOC • Frequency and attendance of EOC rounds • Security of medical biohazardous waste storage areas (4) Medication Management: CS Inspection Program • CS order verification • Inventories of pharmacy prescription pads (5) Women’s Health: Mammography Results and Follow-Up • Communication of results to patients

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Martinsburg VA Medical Center (Facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Credentialing and Privileging; Quality, Safety, and Value; Environment of Care (EOC); Medication Management: Controlled Substances (CS) 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 67 employees. The Facility has generally stable executive leadership and active engagement with employees and patients. Organizational leaders support patient safety, quality care, and other positive outcomes. The OIG’s review of accreditation organization findings, sentinel events, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors; however, the Facility does not have a process established for the collection, tracking, and/or analysis of relevant information related to institutional disclosures. Although the senior leadership team was knowledgeable about selected SAIL metrics, the leaders should continue to take actions to improve care and performance of selected Quality of Care and Efficiency metrics likely contributing to the current 3-star rating. The OIG noted findings in four of the clinical operations reviewed and issued five recommendations that are attributable to the Facility Director, Acting Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Privilege-specific criteria developed and utilized for Focused Professional Practice Evaluations • Service-specific criteria developed and implemented for Ongoing Professional Practice Evaluations (2) EOC • Attendance during EOC rounds (3) Medication Management: CS Inspection Program • Appropriate verifications of CS orders (4) Women’s Health: Mammography Results and Follow-Up • Electronic linking of results to radiology order

The VA Office of Inspector General (OIG) conducted an inspection to evaluate allegations of inadequate staffing of intensivists (physicians who are specialists in the care of critically ill patients) and other Surgery Service concerns at the VA Gulf Coast Healthcare System (System), Biloxi, Mississippi. The OIG substantiated the System did not have full-time intensivist coverage during part of fiscal year 2017. However, the System had taken actions to mitigate patient risk during times that an intensivist was not available, including granting core critical care privileges for hospitalists (physicians who are specialists in the care of patients in the hospital) and diverting admissions for patients possibly needing intensive care unit (ICU) services. The System did not fully comply with risk-based surgical screening processes and selective scheduling of more complex surgeries. The System also did not fully comply with limiting surgeries to patients with pre-operative mortality risk calculations greater than 7.5 percent. The OIG did not find evidence of clinically significant adverse patient outcomes related to this non-compliance. The OIG did not substantiate that ICU patients died from complications as a result of inadequate [intensivist] staffing. Two ICU deaths occurred in late 2017 when an intensivist was not available. In both cases, the patients had metastatic (spread to distant sites) cancer and were subsequently placed on hospice or comfort measures only. The OIG substantiated that some of the intensivist staffing and Surgery Service-related conditions were not remedied after an external inspection. However, the System implemented an action plan to address identified concerns. The OIG also found examples of poor communication and responsiveness, and of improper documentation. The OIG recommended the Veterans Integrated Service Network Director provide oversight of ICU and Surgery Service-related operations until conditions are resolved, and the System Director follow through on incomplete actions and address improper health record documentation by two providers.

An OIG limited review revealed little Department policy or guidance in place regarding the unauthorized disclosure of Department documents to external sources, with the exception of the disclosure of personally identifiable information, proprietary information from companies, and security information.

To see our report, click on the link below