Federal Reports

The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Bath VA Medical Center (facility). This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; Mental Health Residential Rehabilitation Treatment Program; and Post-Traumatic Stress Disorder Care. OIG also provided crime awareness briefings to 29 employees.The facility has generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes. OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results did not identify any substantial organizational risk factors. OIG noted findings in five of the six areas of clinical operations reviewed and issued 11 recommendations that are attributable to the Chief of Staff and Associate Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Credentialing and privileging data reviews• Utilization management documentation(2) Medication Management: Anticoagulation Therapy• Provision of medication education to patients(3) Environment of Care• Environment of care rounds frequency and attendance• Maintenance of required number of filled oxygen tanks and an adequate supply of personal protective equipment• Storage of clean and sterile supplies(4) Mental Health Residential Rehabilitation Treatment Program• Monthly self-inspections, weekly contraband inspections, every 2-hour rounds of public spaces, and daily resident room inspections• Security at entrance doors

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 VA Eastern Kansas 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; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG also provided crime awareness briefings to 118 employees.The facility had generally stable executive leadership and active engagement with employees and patients as evidenced by high satisfaction scores. Organizational leaders support patient safety, quality care, and other positive outcomes (such as initiating processes and plans to maintain positive perceptions of the facility through active stakeholder engagement). OIG’s review of accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and SAIL results did not identify any substantial organizational risk factors.OIG noted findings in four of the six areas of clinical operations reviewed and issued five recommendations that are attributable to the Chief of Staff, Nurse Executive, and Assistant Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value• Review of Ongoing Professional Practice Evaluation data• Documentation of decisions by Physician Utilization Management Advisors(2) Medication Management: Anticoagulation Therapy• Education for patients with newly prescribed anticoagulant medications(3) Environment of Care• Locked Mental Health Unit Interdisciplinary Safety Inspection Team training(4) Long-Term Care: Community Nursing Home Oversight• Cyclical clinical visits

The U.S. Department of health and Human Services (HHS) oversees States' administration of various Federal programs, including Medicaid. State agencies are required to establish appropriate computer system security requirements and conduct biennial reviews of computer system security used in the administration of State plans for Medicaid and other Federal entitlement benefits. This review is one of a number of HHS OIG reviews of States' computer systems used to administer HHS-funded programs.

We conducted a series of OIG audits at four HHS Operating Divisions (OPDIVs) using network and web application penetration testing to determine how well HHS systems were protected when subject to cyberattacks.

Statement of the Honorable Eric M. Thorson, Inspector General, Department of the Treasury, Office of Inspector General, provided to the House Financial Services Committee Subcommittee on Oversight and Investigations for the hearing on "Examining the Office of Financial Research", December 7, 2017 10am. (Written Testimony)

Inspectors General have found significant weaknesses affecting Federal programs serving American Indian and Alaska Native (AI/AN) communities. This report compiles information from recent Office of Inspector General (OIG) audits, evaluations, and investigations to identify vulnerabilities and breakdowns that cut across departments. CIGIE chose this area for study given the level of Federal funding and number of agencies involved, as well as the Federal Government’s special obligation to protect AI/AN interests and fund vital services. Throughout the report, we highlight examples of past OIG findings and recommendations to illustrate these common themes.

The Tennessee Valley Authority's (TVA) Interruptible Power (IP) program implemented new products in October 2015 as part of the product redesign of TVA's demand response portfolio. We initiated this audit in response to concerns forwarded to our office regarding (1) the amount of credits provided through TVA's interruptible products and (2) whether or not these products were a cost effective way for TVA to obtain power. Our audit objective was to determine if the monetary value obtained by TVA during fiscal years 2016 and 2017 was more than the cost of providing these interruptible pricing products to customers. Our audit included interruptible product credits issued and other financial data related to interruption events for participating commercial and industrial customers from October 1, 2015, through March 31, 2017, which totaled $78.5 million. In summary, we found the monetary value obtained by TVA during fiscal years 2016 and 2017 was more than the cost of providing the interruptible pricing products introduced in October 2015 to participating commercial and industrial customers. However, we also found documentation related to the interruptible valuation is not maintained in a central location. We recommended TVA's Vice President, Pricing and Contracts, maintain all supporting documentation related to the annual interruptible valuation in a central location. TVA management agreed with the audit findings and recommendation in this report and plans to take corrective action.(Summary Only)

OIG evaluated whether the Veterans Health Administration (VHA) effectively managed providers’ primary care panels to maximize access to primary care providers by evaluating new enrollee processing into panels as well as the panel sizes. Provider panels define both VHA’s capacity to provide managed outpatient care and provider efficiency based on the number of veterans managed for primary care.In the first seven months of FY 2015, VHA had not effectively managed provider panels to maximize access. VHA facilities’ methods for processing and scheduling veterans into panels varied, and veterans encountered an average wait of 29 days from the date they enrolled until the facility scheduled their appointment. The average of 29 days was not included in VHA’s wait time calculation. VHA facilities had panels below VHA’s panel size recommendations with six of the seven facilities showing panels 13 to 30 percent below the model. This occurred because VHA lacked standard procedures for processing new enrollees, did not track the wait-time from the enrollment to scheduling, and did not ensure compliance with recommended panel sizes. As a result, VHA’s recorded wait times did not accurately reflect the wait experienced. VHA’s recorded wait time showed about 8 percent of newly enrolled veterans waited more than 30 days when OIG determined about 53 percent of newly enrolled veterans completed their first appointment more than 30 days past the determined eligibility date.Lower panel sizes equated to almost $169 million in underutilized provider salaries paid in fiscal year 2015. OIG recommended the Acting Under Secretary for Health establish standardized new enrollee scheduling procedures that properly track wait times and ensure facilities either set panel sizes at VHA’s model goals or justify deviations. The Acting Under Secretary for Health concurred with the recommendations and OIG will monitor VHA’s progress until all proposed actions are completed.