Federal Reports

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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 Grand Junction Veterans 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; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 104 employees.The facility has opportunities to maintain the stability of executive leadership with the appointment of a new facility director. OIG noted that current leaders have active engagement with employees and patients and the Daily Management System has improved the effectiveness and speed of communication. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning (SAIL) results did not identify any substantial organizational risk factors. The leadership team was knowledgeable about selected SAIL metrics and had taken actions to improve performance likely contributing to the current 4-star rating.OIG noted findings in four areas of clinical operations reviewed and issued nine 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 • Physician utilization management advisors’ documentation of decisions • Feedback about root cause analysis actions (2) Medication Management: Anticoagulation Therapy• Process for addressing anticoagulation-related calls outside of business hours• Quality assurance data reviews(3) Coordination of Care: Inter-Facility Transfers• Inter-facility transfer data reporting• Informed consent and communication of pertinent information to receiving facilities(4) Environment of Care• Attendance of Environment of Care rounds• Locked Mental Health Unit employee and interdisciplinary safety inspection team training

We determined that that U.S. Customs and Border Protection (CBP) was caught by surprise when the President issued the Executive Order (EO) on January 27, 2017. DHS had little opportunity to prepare for and respond to basic questions about which categories of travelers were affected by the EO. We found that the bulk of travelers affected by the EO who arrived in the United States, particularly Lawful Permanent Residents (LPR), received national interest waivers. In addition, we observed that the lack of a public or congressional relations strategy significantly hampered CBP and harmed its public image. While the media reported instances of misconduct, we did not substantiate any claims of misconduct on the part of CBP Officers at the ports of entry. Regarding the Department’s compliance with multiple federal court orders that were issued between the January 27, 2017 release of the EO and the February 3, 2017 nation-wide injunction in Washington v. Trump, we found that at the ports of entry, CBP largely complied with court orders, albeit with some delay and confusion as to the scope of some orders. But while CBP complied with court orders at U.S. ports of entry as to travelers who had already arrived, CBP was aggressive in preventing affected travelers from boarding aircraft bound for the United States. We believe those actions violated two separate court orders that enjoined CBP from this activity.

On January 18, 2018, a former Amtrak Customer Service Representative in Indianapolis, Indiana, pleaded guilty to one misdemeanor count of theft of government funds, in violation of 18 U.S.C. § 641. Our investigation determined that the former employee falsified her application for food stamp benefits while employed by Amtrak. The United States District Court for the Northern District of Illinois ordered her to pay $69,091 in restitution to the U.S. Department of Agriculture and sentenced her to two years of probation.

The Office of Inspector General evaluated NASA’s development of the SWOT mission, a space-based satellite that hopes to produce the first global survey of Earth’s surface water, observe details of the ocean’s surface topography, and measure how water bodies change over time.