Federal Reports

The Office of Enforcement and Compliance Assurance, or OECA, is not on track to achieve ten (25 percent) of the 40 measures and deliverables in its National Compliance Initiative, or NCI, strategic plan.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess concerns regarding a primary care provider (provider) potentially falsifying blood pressure readings (blood pressures) at the North Las Vegas VA Medical Center (facility) in Nevada.The OIG determined the provider knowingly documented false blood pressures in patients’ electronic health records (EHRs) during VA Video Connect (VVC) visits. The provider attributed the falsifications to the belief that the VVC template required documentation of a blood pressure when a blood pressure was not obtained and to a lack of VVC training. The OIG confirmed that the VVC template did not require documentation of blood pressures and determined the provider completed required VVC trainings.The provider reported patients were not harmed by the falsifications because mitigation strategies were used. From a review of a sample of EHRs, the OIG determined the provider did not use the mitigation strategies with most patients; however, the OIG did not find evidence that any patients experienced an adverse clinical outcome as a result of the false blood pressures.Upon learning of the provider’s falsification of blood pressures, facility leaders took actions that included retraining and facilitating an EHR review. Despite the retraining, the provider continued to display difficulty demonstrating the use of technology and locating the VVC template. The OIG evaluated a sample of EHRs from the facility’s review and found that not all entries with a blood pressure of 120/80 were clinically reviewed and amended. Additionally, the OIG determined that facility leaders failed to initiate state licensing board reporting processes.The OIG made five recommendations to the Facility Director related to verifying the provider’s ability to complete and document VVC visits, considering administrative action, initiating state licensing board reporting processes, and ensuring the provider’s blood pressure entries in EHRs are reviewed and amended.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess an allegation that a patient received poor care in the Emergency Department at the Baltimore VA Medical Center (facility) in Maryland, which resulted in an amputation at the patient’s left forearm at a non-VA hospital days later. The OIG identified additional concerns related to the patient’s primary care provider not maintaining the patient’s problem list in the electronic health record and Emergency Department providers’ failure to address the patient’s second chief complaint of knee pain.The OIG reviewed the care the patient received at the facility’s Emergency Department on two consecutive days in early fall 2021. During the first visit, the patient, with a medical history of poorly controlled type II diabetes, presented to the facility complaining of left hand pain with a ring stuck on the middle finger after sustaining a fall. The following day, the patient returned with left hand pain; redness, swelling, and a superficial open wound to the finger; and knee pain.The OIG substantiated the patient received poor Emergency Department care during the second visit when a physician assistant failed to obtain laboratory studies for a patient with diabetes and a hand infection, to complete a comprehensive clinical assessment of the patient, and to document a clinical consultation with an attending physician. Additionally, the overseeing attending failed to identify concerns with the physician assistant’s documented care of the patient. The OIG determined these failures may have contributed to the patient’s amputation. An institutional disclosure was conducted, which included a plan for staff training.The OIG made four recommendations to the Facility Director related to ensuring Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints, evaluation of clinical consultation processes, staff training, and maintaining problem lists.

What We Looked AtThe Federal Aviation Administration's (FAA) Office of Audit and Evaluation (AAE) investigates alleged lapses in aviation safety and oversight; violations of FAA regulations, orders, standards, or policies; and other whistleblower disclosures. In December 2020, a Senate committee reported that AAE did not necessarily conduct independent, objective, or impartial investigations and evaluations. In January 2021, the Federal Aviation Administrator asked our office to conduct a review of the office's practices. Our objectives were to evaluate whether AAE (1) aligned its practices for investigations of internal whistleblower safety disclosures with applicable investigative standards, benchmarks, or best practices; (2) documented sufficiency reviews of hotline investigations it referred to FAA lines of business (LOB) with best practices; and (3) complied with requirements in the Aircraft Certification, Safety, and Accountability Act of 2020.What We FoundAAE's investigative practices align with applicable quality standards. However, the office lacks comprehensive written standard operating procedures to reinforce its internal controls. In addition, AAE does not have a method to track and document sufficiency reviews of hotline investigations it referred to FAA's LOBs. Specifically, AAE reviewers did not maintain documentation supporting their sufficiency review conclusions. As a result, AAE cannot demonstrate that its review of investigations it referred to LOBs was of quality and consistent. Finally, FAA has only partially met the Aircraft Certification, Safety, and Accountability Act's requirements for AAE's organizational structure. FAA reorganized AAE in February 2022--renaming one sub-office as the Office of Whistleblower Aviation Safety Investigations and adding an Office of Whistleblower Ombudsman. However, until FAA limits the duties of the AAE Director, which are currently broader, to the specific activities listed in the act, AAE will not have fully implemented the law's requirements.Our RecommendationsWe made four recommendations to improve AAE's compliance with applicable standards and statutory requirements for whistleblower investigations and hotline sufficiency reviews. FAA concurred with all four recommendations and provided appropriate actions and completion dates.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the mental health care of a female patient at the VA Greater Los Angeles Healthcare System (facility) in California, which included that a psychiatry physician resident (psychiatry trainee) was inappropriate during treatment discussions with the patient. The psychiatry trainee utilized a modality called Intensive Short-Term Dynamic Psychotherapy in which a therapist seeks to understand a patient’s interpersonal difficulties, intensify and challenge resistance, analyze transference, explore conflict, and work through unconscious issues.The OIG did not substantiate that the psychiatry trainee’s behavior with the patient was inappropriate. Although the psychiatry trainee did not always engage in effective therapeutic intervention, the OIG was unable to determine that the treatment resulted in a decline in the patient’s mental health causing decreased trust and mental functioning.The OIG found the supervisor did not provide adequate supervision to the psychiatry trainee, to include the psychiatry trainee’s documentation and the supervisor’s documented oversight. The inadequate supervision may have impeded the supervisor’s ability to inform the therapy and hinder the opportunity to achieve a more desirable therapeutic outcome. In addition, the OIG substantiated that Mental Health Department leaders were not responsive to the patient’s concerns. During the inspection, the OIG identified an additional concern regarding the improper creation, storage, and disposition of video recordings and consent forms.The OIG made one recommendation to the Under Secretary for Health to assess the possible scope of current and former VA psychiatry residents being in possession of patients’ personal health information; two recommendations to the Veterans Integrated Service Network Director related to supervision, documentation, document control, and treatment protocols; and three recommendations to the Facility Director related to responses to the patient’s concerns, records, and utilization of video recordings.