Federal Reports

OIG conducted an inspection in response to Senator James Inhofe’s request to evaluate clinical, supervisory, and administrative practices at the Oklahoma City VA Health Care System (System), Oklahoma City, OK. We also evaluated the System Director’s concerns and coordinated parts of this review with The Joint Commission. Our comprehensive review identified multiple program areas, processes, and operations needing improvement. The root cause for many of these issues was poor and unstable leadership at a number of levels, most notably in the Director position. Without strong and effective leadership, an inattentive and apathetic organizational culture evolved that allowed problems to arise and persist. It was only after new leadership was installed in May 2016 that the culture improved and necessary changes took place. We made 24 recommendations.

OIG conducted a healthcare inspection to address concerns received from Congressman Jim Costa in 2014 regarding allegations from an anonymous complainant of Emergency Department (ED)-boarded patients’ length of stay, poor inpatient flow, and nurse staffing shortages at the Central California VA Health Care System (system), Fresno, CA. An anonymous complainant with similar allegations contacted the OIG Hotline in December 2013, July 2014, and February 2015. We requested system leaders respond to the allegations and in their May 2015 response, they acknowledged issues with ED-boarded patients’ length of stay, inpatient flow, and registered nurse staffing, and implemented an improvement plan with 15 actions. In January 2016, we conducted a review of system leaders’ progress after 6 months (July 1, 2015 through December 31, 2015) of implementing their action plans. We found that they did not implement 1 of the 15 actions: system leaders had not established written protocols to identify a process to transfer ED-boarded patients to available VA and non-VA facilities when acute inpatient beds were unavailable. In addition, the system’s policy that addressed the designated location for ED patient overflow did not identify criteria for ED-boarded patients who could be transferred to the Community Living Center. In the course of our review, we identified a patient whose adverse outcome illustrated many of the challenges associated with ED-boarded patients who need to be transferred due to the lack of available inpatient beds. The patient died after a prolonged transport on the maximal dose of a medication generally used in critical care. We made eight recommendations.

For a covered outpatient drug to be eligible for Federal reimbursement under the Medicaid program's drug rebate requirements, manufacturers must pay rebates to the States for the drugs. However, a prior OIG review found that States did not always invoice and collect all rebates due for drugs administered by physicians.

We determined that the Department has addressed the requirements of the Cybersecurity Act of 2015. However, the Department faces challenges effectively sharing cyber threat information across Federal and private sector entities. For example, the system DHS uses does not provide the contextual data needed to effectively defend against threats. DHS lacks a cross-domain information processing solution and automated tools to analyze and share threat information timely. DHS needs to enhance its outreach program to increase participation and improve coordination of information sharing across its partners. Further, our security testing identified configuration and patch management deficiencies related to the systems DHS uses to process and share threat information. We made five recommendations to the National Protection Programs Directorate (NPPD) to enhance the overall effectiveness of DHS’ information sharing program, including acquiring technologies needed for cross-domain sharing and automated analysis of cyber threat data, enhancing outreach to promote sharing, and implementing required security controls on selected information systems. The component concurred with all five recommendations.

Pension Management Centers (PMCs) provide benefits and services to some of the most vulnerable veterans and survivors. OIG’s review focused on rating decisions that addressed original pension benefits and claims processing actions related to Medicaid-covered nursing homes. OIG found St. Paul PMC staff failed to order general medical examinations to support veterans’ pension claims—denying 88 percent of those requiring rating decisions in 2015. St. Paul management and staff misinterpreted Veterans Benefits Administration's (VBA’s) guidance on requesting general medical examinations to support pension claims, and VBA lacked oversight for identifying inconsistent rating practices among PMCs. Consequently, claims processed by the St. Paul PMC were denied more frequently when compared to the Milwaukee and Philadelphia PMCs. Claims processors at the PMCs also delayed and inaccurately processed pension benefits reduction cases whenever beneficiaries resided in Medicaid-covered nursing care facilities. Delays and inaccuracies found in 1,900 of 2,800 Medicaid benefits reduction cases completed in 2015 resulted in an estimated $6.9 million in improper benefits payments. If the PMCs continue to delay and inaccurately process these adjustments, VBA will pay approximately $34.5 million in improper benefits from Calendar Year (CY) 2016 through CY 2020. Generally, VBA did not prioritize this workload, performance measures for Medicaid-covered nursing home care reduction cases were lacking, and PMCs did not provide training specific to Medicaid-covered cases. OIG recommended that VBA clarify guidance and provide training on ordering general medical examinations to support original pension claims, review denied pension claims to determine whether examinations were required, and implement a plan to ensure rating consistency. We also recommended that VBA prioritize benefit reduction actions and develop workload performance measures for benefits reduction cases associated with Medicaid-covered nursing homes.

This audit sought to determine whether the National Pension Call Center (NPCC) is providing timely and quality assistance to veterans and their families. OIG found Veterans Benefits Administration (VBA) management needed to improve the NPCC’s oversight of quality review and training processes. Specifically, NPCC supervisors did not review or take corrective actions for calls evaluated by quality-review specialists. Calls in Spanish were not included in Benefits Assistance Service (BAS) quality-review monitoring, and NPCC management and call agents did not complete or properly record all required training. VBA management lacked reasonable assurance that the NPCC’s hours of operation provided sufficient availability for pension recipients to speak with agents. Also, the Philadelphia VA Regional Office (VARO) staff mailed documentation that included personally identifiable information (PII) to incorrect addresses. This occurred because the NPCC coach did not implement a process requiring corrective actions to address low-scoring quality review results. BAS has never had a quality-review specialist fluent in Spanish to evaluate calls. The NPCC and BAS management provided inadequate oversight to ensure staff received or completed the required training. VBA management did not analyze the available call data to determine the number of calls that go unanswered after the close of NPCC’s business day. The Philadelphia VARO’s controls for outgoing mail processes needed strengthening. OIG recommended VBA implement controls to ensure callers receive accurate and complete responses to pension inquiries, BAS has qualified staff to evaluate the quality of Spanish-speaking calls, and required training is completed and recorded timely and to continuously evaluate data for calls made outside of normal business hours. OIG also recommended the Philadelphia VARO Director strengthen controls at the VARO to ensure documents that include PII are mailed to the intended veteran. The Acting Under Secretary for Benefits concurred with our findings and recommendations. We considered the corrective action plans acceptable and will follow up on their implementation.