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Brought to you by the Council of the Inspectors General on Integrity and Efficiency
Federal Reports
Report Date
Agency Reviewed / Investigated
Report Title
Type
Location
Department of Veterans Affairs
Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri
The VA Office of Inspector General (OIG) conducted an inspection to evaluate the care provided to a patient who died by suicide in the Emergency Department and assessed leadership failures related to the event at the John Cochran Division of the VA St. Louis Health Care System (facility) in Missouri.The OIG determined that deficiencies in the quality of Emergency Department care provided to the patient resulted in a delay of care and may have contributed to the patient’s death. The OIG found that an Emergency Department nurse may not have properly administered a suicide risk screen and did not monitor the patient after triage. The OIG determined that an Emergency Department physician did not evaluate the patient due to the nurse’s failure to communicate that the patient was awaiting evaluation. Over two hours and twenty minutes elapsed from the time the patient arrived in the Emergency Department to the time the patient was found unresponsive. The OIG found deficiencies related to the root cause analysis process and determined that facility leaders did not complete a timely institutional disclosure or comply with Veterans Health Administration requirements in reporting to state licensing boards. The OIG also identified a concern related to the chief of the Emergency Department’s conduct, specifically their attempt to direct staff responses during the OIG inspection. The OIG made six recommendations to the Facility Director related to the chief of the Emergency Department’s conduct; standardized administration of the suicide risk screen; monitoring Emergency Department patients; completion of root cause analyses and administrative investigations on the same event; completion of institutional disclosures within required time frames; and state licensing board reporting.
U.S. Customs and Border Protection (CBP) apprehended and subsequently released a migrant without providing information requested by the Federal Bureau of Investigation’s Terrorist Screening Center (TSC) that would have confirmed the migrant was a positive match with the Terrorist Screening Data Set (Terrorist Watchlist). This occurred because CBP’s ineffective practices and processes for resolving inconclusive matches with the Terrorist Watchlist led to multiple mistakes. For example, CBP sent a request to interview the migrant to the wrong email address, obtained information requested by the TSC but never shared it, and released the migrant before fully coordinating with the TSC.
The VA Office of Inspector General (OIG) conducted this review to assess the VA Philadelphia Healthcare System’s oversight and stewardship of funds and to identify potential cost efficiencies. The review assessed the following financial activities and administrative processes to determine whether the healthcare system had appropriate oversight and controls in place: open obligations oversight, purchase card use and oversight, inventory and supply management, and pharmacy operations.The OIG found that the healthcare system could improve the following:• Deobligation of residual funds. Six of 10 sampled open obligations had residual funds totaling about $44,500 that should have been promptly deobligated.• Management of purchase card transactions. Potential noncompliance errors in about 18,500 purchase card transactions led to about $16 million in questioned costs. The healthcare system also may have missed cost savings on frequently used goods.• Inventory management. Inventory management could be made more efficient by ensuring stock levels and inventory values are recorded correctly, establishing local processes and procedures for monitoring inventory reports, implementing a plan for staff training to increase awareness of internal controls and data reliability in the inventory system, and ensuring all supply chain performance measures are maintained in compliance with VA policy.• Pharmacy efficiency. The healthcare system could narrow the gap between observed and expected drug costs, avoid end-of-year purchases, and meet requirements for monthly reconciliation reporting.VA concurred with the OIG’s 12 recommendations made to the healthcare system director to use as a road map to improve financial operations. The recommendations address issues that, if left unattended, may eventually interfere with effective financial efficiency practices and the strong stewardship of VA resources.
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Phoenix VA Health Care System, which includes the Carl T. Hayden VA Medical Center and multiple outpatient clinics in Arizona. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (emergency department and urgent care center suicide prevention initiatives)The OIG issued six recommendations for improvement in four areas:1. Leadership and organizational risks• Institutional disclosures2. Quality, safety, and value• Peer review committee recommendations for improvement actions• Review of peer review committee’s summary analysis3. Medical staff privileging• Professional practice evaluations4. Environment of care• Inspections• Video recording
This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice (DOJ) or a non-DOJ federal agency had fully implemented them. The list omits information that DOJ determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.
EPA issuance of informative BEACH Act reports would allow Congress to make informed program decisions, improve program oversight, and enhance transparency.
Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the Georgia Criminal Justice Coordinating Council to Women Moving On, Inc., Decatur, Georgia