Federal Reports

The Federal Managers’ Financial Integrity Act (FMFIA), P.L. 97-255, as well as the Office of Management and Budget’s (OMB) Circular A-123, Management Accountability and Control, establish specific requirements for management controls. Each agency head must establish controls to reasonably ensure that: (1) obligations and costs are in compliance with applicable laws; (2) funds, property and other assets are safeguarded against waste, loss, unauthorized use, or misappropriation; and (3) revenues and expenditures applicable to agency operations are properly recorded and accounted for in order to permit the preparation of reliable financial and statistical reports, as well as to maintain accountability over the assets. FMFIA further requires each executive agency head, on the basis of an evaluation conducted in accordance with applicable guidelines, to prepare and submit a signed statement to the President disclosing that the agency’s system of internal accounting and administrative control fully comply with requirements established in FMFIA.

OIG conducted a healthcare inspection to follow up on concerns regarding access to care in the urology service at the Phoenix VA Health Care System (system) in Phoenix, Arizona. We limited our inspection to determining whether a delay in care was associated with adverse patient impact.During OIG’s 2014 review of system scheduling practices and wait times, we reported that large numbers of patients referred for urological evaluation and/or treatment experienced significant delays. The delays involved obtaining an appointment, scheduling follow-up, and/or receiving authorizations for non-VA urology care (see: Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System, Phoenix, Arizona; [Report No. 14-02603-267, August 26, 2014]). OIG’s Office of Healthcare Inspections opened an expanded review focusing on access to urology care at the system. An interim report Review of Phoenix VA Health Care System’s Urology Department Phoenix, Arizona; (Report No. 14-00875-112, January 28, 2015), detailed our findings regarding incomplete documentation for 759 urology patients and the potential impact on care. In Review of Access to Urology Service at the Phoenix VA Health Care System, Phoenix, Arizona; (Report No. 14-00875-03, October 15, 2015), we found a significant urology staffing shortage, inconsistent non-VA urology provider documentation of patient care, and untimely care to patients needing urological services. We committed to reviewing the records and management of the 759 patients once the Veterans Health Administration provided us with the necessary documentation. This report details these findings. We determined that 148 (20 percent) of the 759 patients experienced delays in getting new evaluations or follow-up appointments. When a delay was identified, we assessed the impact of that delay on the patient’s care. From a clinical standpoint, we found that none of the patients were adversely impacted by a delay in care.

OIG conducted a healthcare inspection to assess whether safety screenings were performed and documented prior to magnetic resonance imaging (MRI) at the Central Alabama Veterans Health Care System (system), Montgomery, AL. The system has an agreement with a Department of Defense clinic, Lyster Army Health Clinic (Lyster), for MRI services. Lyster staff do not have access to VA electronic health records (EHRs) and system staff do not have access to Lyster EHRs. A powerful magnetic field around MRI scanners creates safety risks. Safety screening is critical to alert staff of patients’ electronic, mechanical, or magnetic implants. VHA requires pre-MRI initial and secondary safety screenings. We did not find a VHA or system policy addressing documentation requirements of MRI safety screening forms completed at non-VA facilities. We reviewed 158 of 2,753 MRI orders (6 percent) completed at the system or at Lyster from September 22, 2014 through September 22, 2015, to assess documentation of initial and secondary safety screenings. In September 2015, the system took steps to ensure that staff completed initial safety screening forms when the MRI was ordered for patients receiving MRIs at Lyster. We found 17 patients who received MRIs at Lyster without initial safety screenings. However, Lyster staff had completed and documented the secondary safety screenings in the Lyster EHRs, and completed the MRIs. We reviewed the 158 patients for secondary screenings. Secondary safety screening forms were not available in VHA EHRs but were in the Lyster EHRs; copies of the completed forms would be made available upon request. To evaluate safety screening documentation after September 2015, we reviewed 50 of 475 MRI orders (10.5 percent) placed in July 2016. Ten of the 50 were excluded. We found that the remaining MRI orders included the initial safety screening in the VHA EHR.

OIG evaluated controls over the health care enrollment program administered at VA medical facilities and determined if enrollment actions were processed timely and supported by required documentation. OIG found that VHA did not provide effective governance necessary to ensure oversight and control over the health care enrollment program medical facilities. Specifically, VHA required medical facilities to establish procedures for processing enrollment applications without implementing effective processes to monitor those activities. Only 38 of 106 VA medical facilities sampled had local enrollment policies. Medical facilities that did have guidance were permitted to adopt practices that were inconsistent with national policies. Conflicts between local practices and national policies occurred because VHA lacked appropriate guidance, oversight, and monitoring to ensure a standardized enrollment process. Formal training was also not provided to eligibility and enrollment staff at VA medical facilities. OIG also found that data systems did not have the capability to identify new enrollment applications or provide the basis for independent testing of timeliness or supporting documentation. Based on a statistical sample, OIG projected that only 197,000 of 427,000 enrollment records in the universe represented FY 2015 applications for enrollment. Further, OIG could not make conclusions related to timeliness or supporting documentation. This occurred because VHA did not adequately monitor program effectiveness or ensure that accurate data were available for program transparency. OIG recommended VHA develop standardized national policy and procedures, implement national oversight, and provide mandatory and standardized training for the health care enrollment program at VA medical facilities. OIG also recommended VHA implement a plan to correct the data integrity issues necessary to improve the accuracy and timeliness of health care enrollment data.