Federal Reports

Please click the link below to access a press release describing this and other related documents.

Please click the link below to access a press release describing this and other related documents.

Please click the link below to access a press release describing this and other related documents.

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Clement J. Zablocki 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; Coordination of Care: Inter-Facility Transfers; Environment of Care (EOC); High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home (CNH) Oversight. The OIG provided crime awareness briefings to 93 employees. The facility has generally stable executive leadership and active engagement with employees and patients; however, the senior leadership team has opportunities to improve patient safety, quality care, and perceptions about facility leadership. The OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results identified multiple organizational risk factors that may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented. The senior leadership team should continue to take actions to improve performance of the Quality of Care and Efficiency metrics likely contributing to the current 3-star SAIL rating. The OIG noted findings in five of the six areas of clinical operations reviewed and issued 10 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, and Deputy Director. The identified areas with deficiencies are: (1) QSV • Review of credentialing and privileging data (2) Coordination of Care: Inter-Facility Transfers • Transfer data collection and reporting • Transfer documentation • Resident supervision • Communication with the accepting facility (3) EOC • EOC rounds frequency and attendance • Training for locked mental health unit employees (4) High-Risk Processes: Moderate Sedation • Training for staff who perform moderate sedation (5) Long-Term Care: CNH Oversight • Clinical visits for patients residing in CNHs

The VA Office of Inspector General (OIG) conducted this audit at the request of Senator Johnny Isakson who was concerned that delays in the repair of VA-issued power wheelchairs and scooters at the Atlanta VA Health Care System placed veterans at physical and financial risk. To evaluate these concerns, the OIG assessed the timeliness of power wheelchair and scooter repairs at Veterans Integrated Service Network (VISN) 7 VA medical facilities. The OIG confirmed that VISN 7 medical facilities, including the Atlanta VA Health Care System, did not ensure the timely completion of repair. The OIG used a 30-day benchmark to assess timeliness because Prosthetic and Sensory Aids Service does not have a timeliness standard for the completion of repairs. Subsequently, the OIG projected 380 veterans in VISN 7 experienced delays in the completion of approximately 480 repairs in FY 2016. Furthermore, these veterans waited an average of 69 days for their repairs to be completed. These delays occurred because VISN 7 Prosthetic Service managers lacked policies to ensure VA medical facility staff promptly input repair requests and prosthetic service purchasing staff monitored repairs from inception to completion and held vendors accountable for the timely completion of repairs. Although the OIG could not confirm that the delayed power wheelchair and scooter repairs financially impacted veterans, it confirmed that some veterans experienced physical hardships related to the delays. The OIG recommended the VISN 7 Director implement controls to ensure VA medical facility staff: initiate repair consults as soon as repair requests were received; follow consult documentation procedures; monitor and follow up on repairs through completion; and monitor vendors to ensure the completion of repairs by agreed-upon delivery dates. The VISN 7 Director concurred with our report and recommendations and provided an action plan to address the recommendations. The OIG considered the action plan acceptable.

We found that the company appears to be identifying only a small portion of potentially fraudulent medical claims made by individual medical service providers. Our work indicated that 14 percent of claims submitted by physicians, nurses, physical therapists and other individual providers from 2013 to 2015 were potentially fraudulent, which is significantly higher than the 1 percent of claims identified by the company’s primary claim administrator.