Federal Reports

The OIG evaluated allegations that staff at the Richard L. Roudebush VA Medical Center (facility) provided inadequate alcohol withdrawal management in the Emergency Department for a patient who died approximately two days after discharge, inadequately responded to the patient’s urgent care needs, and failed to provide posttraumatic stress disorder (PTSD) care. During the inspection, the OIG also identified concerns related to discharge care coordination, leaders’ failure to consider an institutional disclosure, and adequacy of primary care assessments and documentation regarding the patient’s alcohol use and safe transport.The OIG substantiated that Emergency Department staff mismanaged the alcohol withdrawal care of the patient, and that a medical support assistant inadequately responded to the patient’s report of “bad” withdrawal symptoms and lack of transportation to the Emergency Department. It was not substantiated that facility staff failed to provide PTSD care.Facility leaders had not established procedures for care coordination of patients discharged from the Emergency Department. The extent of family member involvement in the patient’s discharge planning could not be determined because of the absence of documentation and conflicting reports.Although the OIG determined an institutional disclosure should have been considered following the patient’s adverse clinical outcome, facility leaders told the OIG that it was not considered because internal reviews did not warrant that action.A nurse practitioner failed to thoroughly assess the patient’s substance use, schedule follow-up, and discuss immediate safety concerns.The OIG made seven recommendations to the Facility Director related to a review of the patient’s care, evaluation of the Emergency Department alcohol withdrawal management protocol, consideration of written Emergency Department discharge planning and care coordination guidance, consideration of institutional disclosure, establishment of administrative staff protocol for urgent care needs, and primary care procedures for management of intoxicated patients.

We identified gaps in Ginnie Mae’s guidance and process for troubled issuers. Ginnie Mae made progress in developing an issuer default governance framework, but has not (1) defined its authorities for marketing troubled portfolios; (2) formalized guidance for how to identify potential buyers before extinguishment; (3) established expectations for determining portfolio value, price before sale, and evaluation against other options or (4) included a step to evaluate prospective purchasers’ ability to absorb an extinguished portfolio. Additionally, we found Ginnie Mae had implemented our previous recommendation to develop and implement controls to determine the total impact of a large- or multiple-issuer default, the maximum-size default Ginnie Mae could adequately execute, and individual issuers’ ability to adapt to changing market conditions, but there was a gap related to the semiannual capacity reports submitted by master subservicers (MSS).

We verified the OSMRE implemented 9 of the 11 recommendations we made in a 2017 evaluation report.