Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Alexandria VA Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; Long-Term Care: Community Nursing Home Oversight; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 105 employees.The facility has stable executive leaders who support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, and Patient Safety Indicator data did not identify any substantial organizational risk factors. The executive leaders appear to have active engagement with employees but need to continue efforts to improve patient experience scores. The leaders also seemed knowledgeable about selected Strategic Analytics for Improvement and Leaning (SAIL) metrics but should make significant efforts to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 2-star SAIL rating.OIG noted findings in five of the six areas of clinical operations reviewed and issued nine recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value• Review of Ongoing Professional Practice Evaluation data(2) Medication Management: Anticoagulation Therapy• Patient education specific for newly prescribed anticoagulant medications(3) Environment of Care• Participation on environment of care rounds• Safe and clean environment in all patient care areas• Locked mental health unit employee and Interdisciplinary Safety Inspection Team training(4) Long-Term Care: Community Nursing Home Oversight• Community Nursing Home Oversight Committee representation • Cyclical clinical visits(5) Post-Traumatic Stress Disorder Care• Suicide risk assessments• Referral for diagnostic evaluations

The Administration for Children and Families (ACF) had a process in place to ensure that Head Start grantees took corrective action on A-133 audit findings. Head Start grantees are required to have Single Audits conducted in accordance with Office of Management and Budget Circular A 133 (also known as A-133 audits) for fiscal years beginning before December 26, 2014. However, for Region II Head Start grantees that submitted audit reports to the Federal Audit Clearinghouse, ACF did not always resolve recurring audit findings in accordance with Federal requirements and ACF policies and procedures. Specifically, ACF did not issue letters transmitting management decisions for six of the eight audit reports we reviewed within 6 months after receiving the reports. In addition, although ACF provided the grantees with letters stating that the corrective actions planned or taken should prevent recurrence of the findings, ACF did not establish specific dates for grantees to correct deficiencies noted in the audit reports. Finally, ACF did not always follow up with grantees to ensure that they actually took corrective actions to resolve audit findings. The prompt resolution of audit findings helps ensure that Federal funds are effectively and efficiently used to carry out the activities for which they were authorized.

The Health Resources and Services Administration (HRSA) awarded Henry J. Austin Health Center, Inc. (HJAHC), a not-for-profit organization, $8.3 million in grant funds through several Community Health Center Program grants to provide comprehensive primary care services in the Trenton, New Jersey, area. Of this amount, $281,000 was to support certain activities (i.e., one-time equipment purchases).

OIG investigated allegations that an employee at the Office of the Special Trustee for American Indians (OST) lied about her cancer diagnosis, forged medical records, falsified documents, and abused her own sick leave and leave donated by coworkers.Our investigation confirmed the allegations. We found no evidence that the OST employee had been diagnosed with cancer or that she received medical care for cancer as she claimed. On 15 occasions, the employee submitted physicians’ notes to OST containing forged signatures from 5 separate medical providers. As a result of the falsified physicians’ notes, the employee was authorized 256 hours of her own sick leave and received 28 hours of donated leave from her coworkers.The employee left the Department before we issued our report.

The OIG investigated allegations that the Bureau of Land Management’s (BLM’s) Wyoming State Office (WYSO) had entered into an unneeded contract for oil-and-gas-record digitization services, had improperly selected the contractor, and had improperly carried the funds for the digitization project across fiscal years. We also investigated an allegation that WYSO had not received proper compensation for record copying and other clerical services it had performed for an oil and gas company.Our investigation did not substantiate these allegations. The BLM Washington (DC) Office had encouraged WYSO and other state offices to identify high-value records, which included WYSO’s oil and gas records, and to begin digitizing them to improve record retention and reduce costs for storing physical records. WYSO used a contractor that was competitively selected by the U.S. Government Publishing Office to provide scanning and digitization services to multiple Federal agencies. We confirmed that WYSO had carried funds used for this project across fiscal years, but we learned that it had the authority to do so and used the appropriate financial mechanism. We also confirmed that WYSO was paid for the copies and the other services it provided to the oil and gas company.