Federal Reports

The OIG investigated allegations that a BIA manager had sexually harassed his direct subordinate.The employee and two other women, both of whom had reported to the manager in the past, told us that he had subjected them to unwelcome and inappropriate touching or sexual remarks. The employee said the manager touched her inappropriately and made unwelcome remarks of a sexual nature to her. The second woman, also a BIA employee, said the manager had made inappropriate remarks to her when she worked for him. The third woman, who no longer worked for the BIA, said that when she worked for the manager he had regularly hugged her when she did not want him to.When we interviewed the manager, he denied most of the allegations against him, but he later admitted it was possible he had made an inappropriate remark to the first employee. The manager left the Department after we began our investigation.We also found during our investigation that two regional BIA managers knew about some of the manager’s alleged misconduct and should have acted sooner to address it.

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OIG conducted a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Southern Oregon Rehabilitation Center and Clinics (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; Environment of Care; Long-Term Care: Community Nursing Home Oversight; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 64 employees.The facility has opportunities to improve the stability of executive leadership and patient satisfaction. However, OIG’s review of accreditation organization findings, sentinel events, disclosures, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The senior leadership team was generally knowledgeable about selected SAIL metrics but should continue to take actions to improve care and performance, particularly Quality of Care and Efficiency metrics likely contributing to the current 1-star rating.OIG noted findings in five areas of clinical operations reviewed and issued eight recommendations that are attributable to the Facility Director, Chief of Staff, and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Root cause analyses completion(2) Medication Management: Anticoagulation Therapy• Quality assurance data reviews(3) Environment of Care• Environment of care rounds attendance(4) Long-Term Care: Community Nursing Home Oversight• Oversight committee membership and attendance• Cyclical clinical visits(5) Mental Health Residential Rehabilitation Treatment Program• Weekly contraband inspections• Closed circuit television surveillance system• Signage to alert patients and visitors of recording.