Federal Reports

OIG conducted a healthcare inspection to assess allegations made by confidential complainants regarding quality of care and other concerns at the Captain James A. Lovell Federal Health Care Center (FHCC), North Chicago, IL. We substantiated the Home Based Primary Care program’s Joint Commission accreditation status was “threatened” after a March 2015 FHCC accreditation survey; however, in August 2015, the Joint Commission determined the program complied with accreditation standards.We substantiated a Community Living Center patient who fell had an inaccurately low Morse Fall Scale assignment and incomplete Morse Fall Scale Notes. We substantiated that Community Living Center patient falls increased during fiscal year (FY) 2014; however, facility leadership recognized the issue and completed an action plan, which led to a decrease in patient falls in FY 2015.We substantiated the Emergency Department (ED) was left unattended by a qualified physician when ED physicians left the ED to perform emergency airway management in other FHCC care areas. We substantiated the ED did not have clerical staff support on weekends and most weekdays during the dayshift; however, this did not conflict with Veterans Health Administration policy and did not negatively affect delivery of patient care. We did not substantiate the ED length of stay for admitted patients was long or that ED transfer rates were high. We substantiated nurses did not consistently follow proper hand-hygiene practices. We substantiated primary care providers referred Navy recruits to the ED for non-emergent care needs; however, we determined the practice was permitted to ensure recruits were ready for deployment. We did not substantiate FHCC staff mishandled the suicides of two individuals. We did not substantiate the medical/surgical unit length of stay was long. We did not substantiate the Associate Director of Inpatient Services lacked the required education and experience to qualify for the position.We made three recommendations.

We determined that although a complainant alleged there were systemic security challenges in the Office of Intelligence and Analysis (OIA), there were few documented security incidents over the past 5 years, all of which OIA addressed with corrective actions. Further, OIA has improved the effectiveness of its Field Intelligence Division and the Field Intelligence Officers by hiring qualified, experienced intelligence professionals and implementing clear policies and procedures, but it could enhance officer training. OIA is also addressing weaknesses in coordination among its watches and perceived delays in intelligence reporting. We made two recommendations to improve the effectiveness of OIA operations; the Transportation Security Administration (TSA) concurred with both recommendations.

Our audit determined that Western Governors University did not comply with the institutional eligibility requirement that limits the percentage of students who may enroll in correspondence courses. As a result, the school received more than $712 million in Federal student aid funds that it was not eligible to receive. We also found that the school did not comply with requirements governing Federal student aid disbursements and did not always comply with the requirements governing the return of Federal student aid.