Federal Reports

This administrative investigation addressed concerns of possible misconduct by two leaders responsible for overseeing medical facility staff training on implementing VA’s new multibillion-dollar patient electronic health record system. The investigation stemmed from a prior OIG review at the initial operating site (the Mann-Grandstaff VA Medical Center in Spokane, Washington), during which OIG healthcare inspectors experienced significant challenges in receiving timely, complete, and accurate information from the then VA Office of Electronic Health Record Modernization’s (OEHRM’s) Change Management group.The investigation revealed that while the Change Management leaders did not intentionally seek to mislead the OIG, their lack of diligence resulted in delays and misinformation being submitted that impeded oversight efforts. Failures included (1) submitting a training evaluation plan without disclosing to the OIG that it was in its “infancy” and had not been fully implemented or even approved; (2) delaying production of requested proficiency check datasets that should have been available under the submitted evaluation plan; (3) instead providing three summary statistics with errors that doubled the training proficiency test pass rate from initial findings of 44 to 89 percent, without the requested methodology; (4) overlooking red flags indicating that all failing scores had in fact been removed from reported rates (with the total number of proficiency tests dropping by more than 3,000 in submitted recalculations); and (5) failing to disclose concerns regarding data reliability and that data were excluded.VA concurred with the OIG’s two recommendations for providing guidance to staff in the since-reorganized Electronic Health Record Modernization and Integration Office on providing timely, complete, and accurate responses to OIG staff and ensuring direct staff-level communications with OIG personnel are not impeded. VA also agreed to consider whether administrative action is appropriate given the conduct and performance of the two Change Management leaders.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the leadership performance and oversight by Veterans Integrated Service Network (VISN) 5: VA Capitol Health Care Network in Linthicum, Maryland, covering leadership and organizational risks and key processes associated with promoting quality care. This inspection also focused on COVID-19: Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Credentialing; Environment of Care; Mental Health: Suicide Prevention; Care Coordination: Inter-facility Transfers; and Women’s Health: Comprehensive Care.The executive leaders, who had worked together since August 2020, had spent much of their time and efforts on improving care and leadership at the Louis A. Johnson VA Medical Center following an OIG criminal investigation of a VA nursing assistant who was convicted and sentenced for the murder of seven veterans. Leaders reported taking actions such as ensuring staff completed Morbidity and Mortality reviews, evaluating quality of care through an Administrative Investigation Board, and monitoring hiring and background check processes.Selected survey scores related to employee satisfaction with VISN leaders generally exceeded VHA averages; however, the Deputy Network Director’s servant leadership score was lower than the VHA average. VISN patient experience survey scores were similar to VHA averages, except for inpatient care satisfaction at selected VISN 5 facilities. The OIG identified potential risk factors including mental health wait times at selected facilities over 20 days, higher rates of clinical vacancies, and challenges with facility hiring support and retention of human resources staff. The Network Director, Chief Medical Officer, and Quality Management Officer/Chief Nursing Officer had opportunities to improve oversight of facilities’ quality, safety, and value; care coordination; and high-risk processes.The OIG issued one recommendation for improvement:(1) Medical Staff Credentialing• Physician credentials review process

The Office of Inspector General (OIG) conducted an inspection to assess a safety concern with the new electronic health record (EHR) that resulted in patient harm. The OIG found that the new EHR sent thousands of orders for medical care to an undetectable location, or unknown queue, instead of to the intended location. Veterans Health Administration (VHA) identified and ranked safety concerns with the new EHR. In December 2021, VHA assessed the risk of the unknown queue as “major severity,” “frequently occurring,” and “very difficult to detect.” As such VHA recognized immediate mitigation was needed. Oracle Cerner failed to inform VA end-users of the existence of the unknown queue and put the burden on VHA to mitigate the problem.Beginning in June 2021, VHA staff spent substantial hours to complete clinical reviews to assess patient risk and harm related to the unknown queue and found that the new EHR’s delivery of orders to the unknown queue caused 149 patient harm events.In late 2021,VHA staff provided the Deputy Secretary and the Executive Director for VA’s EHR modernization effort with information on the unknown queue safety concern and identified patient harm. Each facility that goes live with the new EHR will require an ongoing commitment from facility staff to monitor and address the new EHR’s unknown queue. Cerner and VHA took actions to minimize orders being routed to the unknown queue. However, after finding over 200 orders in the unknown queue in May 2022, the OIG has concerns with the effectiveness of Cerner’s plan to mitigate the safety risk.

The objective was to determine the extent to which the Public Assistance Alternative Procedures (PAAP) met the goals set forth in Section 428 of the Stafford Act and did so in accordance with legislation and FEMA guidelines since the alternate procedures were made available in 2013.

We determined whether FSIS’ actions taken in response to complaints of sexual misconduct and harassment in the workplace, received October 1, 2019, through May 31, 2021, were in accordance with Departmental and agency policy.

The USPP supervisor used his GOV to drive to and from his approved outside employment on 10 occasions in 2021, in violation of law and USPP policy.

The unclassified version of the SAR covers the period from 1 October 2021 – 31 March 2022, and reflects what the NSA OIG could release publicly about its work for that SAR Report Cover reporting period. The OIG made 171 recommendations that we believe will be impactful in improving the economy, efficiency, and effectiveness of this critical Agency's operations.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Chouteau Station in St. Louis, MO (Project Number 22-115-3). The Chouteau Station is in the Kansas-Missouri District of the Central Area and services ZIP Code 63110, which serves about 17,235 people and is considered to be urban. We judgmentally selected the Chouteau Station based on the number of Stop-the-Clock (STC) scans occurring at the delivery unit rather than at the customer’s point of delivery.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Maryville Gardens Station in St. Louis, MO (Project Number 22-115-2). The Maryville Gardens Station is in the Kansas-Missouri District of the Central Area and services ZIP Codes 63104, 63111, and 631181 which serve about 65,703 people and are all considered urban communities. We judgmentally selected the Maryville Gardens Station based on the number of Stop-the-Clock (STC) scans occurring at the delivery unit rather than at the customer’s delivery address.