Federal Reports

The OIG conducted a healthcare inspection at the Charlie Norwood VA Medical Center in Augusta, Georgia (facility) to evaluate the adequacy of a patient’s outpatient care in the months prior to surgery and during preoperative and postoperative care. After surgery, the patient was admitted for orthostatic hypotension and physical deconditioning and placed under hospice care. The patient subsequently suffered alcohol withdrawal and declining health, and died in the intensive care unit. Prior to the patient’s surgery, primary care staff failed to provide sufficient care coordination and treatment. A provider failed to address the patient’s abnormal chest images and poor nutrition, and failed to communicate test results to the patient as required. A primary care nurse failed to respond to the patient’s secure message request for assistance two days before surgery. Additionally, a barium swallow test was not scheduled. The surgical team completed a preoperative assessment but failed to detect the patient’s overall poor health. During the patient’s hospital stay after surgery, medical-surgical nurses did not consistently assess alcohol withdrawal symptoms or administer medications as required. The OIG also found the facility’s alcohol withdrawal protocol could be discontinued prior to the onset of a patient’s withdrawal symptoms. Medical-surgical unit nursing leaders did not have adequate quality controls or training in place to ensure the provision of safe and effective alcohol withdrawal nursing care. The OIG made one recommendation to the Veterans Integrated Service Network Director to review the provider’s care of the patient. Nine recommendations were made to the Facility Director related to same-day care access, communication of test results and treatment plans, assigned surrogates, preoperative care, medical-surgical nurses’ patient care, Trendelenburg position usage and staff education, nursing competencies for alcohol withdrawal assessments and treatment, medical-surgical unit nurses’ quality control oversight, and the facility’s alcohol withdrawal treatment protocol.

The VA Office of Inspector General (OIG) conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Center in Ohio.One allegation involved an urgent care provider sending a patient with a T12 vertebrae compression fracture to have chiropractic care at the Complementary and Alternative Medicine (CAM) clinic. The patient returned a week later with a T12 burst fracture and rib fractures.The OIG found that an urgent care provider verbally referred a patient for pain management and not for chiropractic care. However, the OIG found that the urgent care provider did not enter a CAM consult until eight days after seeing the patient. Due to this delay, the chiropractor and clinical massage therapist failed to review the consult prior to seeing the patient. Additionally, the chiropractor and massage therapist could not link documentation to the consult and had no other process to complete the documentation resulting in the failure to document care provided within the medical record.The patient returned to the Urgent Care Center eight days later where a computerized tomography scan showed an acute burst fracture and acute rib fractures. Because of the lack of documentation and provider recall, the OIG could not conclusively determine the relationship between the actions taken by the chiropractor and clinical massage therapist and the patient’s bone fractures.The OIG found the nine additional allegations to be unsupported and lacked merit.The OIG made two recommendations to the Facility Director related to education of providers, chiropractors, and clinical massage therapists on the use of consults and timely documentation, and conducting an internal review of the CAM program processes related to patient care, reviewing consults, scheduling appointments, checking-in patients, and documentation.

Objective: To determine whether the Social Security Administration (SSA) met all requirements of the Payment Integrity Information Act of 2019 (PIIA) in the Fiscal Year (FY) 2021 Agency Financial Report (AFR) and accompanying materials.

Our objective for this report was to assess the extent to which the company planned effectively for the Unified Operations Center (UOC) program, including developing a business case that demonstrated the expected financial and operational benefits compared to the estimated costs.The company began planning for the UOC program in December 2018. It is a multi-year effort to relocate several vital customer care functions—including train-dispatching personnel who are currently spread across five cities—into a centralized location. Mitigating flooding risks at the current Consolidated National Operations Center, located on the Christina River in Wilmington, Delaware, was another reason the company planned to move personnel to the new building. In May 2020, the company purchased a building in Wilmington for $41.1 million to house the UOC program.We found that the company experienced challenges associated with its building purchase, which have led to questions about how the company will use the property. Specifically, the purchase was largely premised on two significant yet faulty assumptions: (1) that the company could centralize and collocate its train control and dispatch personnel, a specialized Amtrak Police Unit, social media staff, and relocate IT personnel from leased office space; and (2) that the program would yield cost savings. Neither assumption materialized because the company did not effectively verify the feasibility of centralizing these personnel and functions—including retrofitting the building to accommodate significant IT requirements—before purchasing the building in May 2020. The company is in the early stages of design work to retrofit the building to accommodate the UOC program at an estimated cost of $37 million, and it is updating its business case for the program’s future.To help the company make more informed decisions about the future of the UOC program, the building it purchased, and the best use of resources, we recommended that it verify the assumptions in its revised business case about the UOC program’s functions and staff relocations, as well as develop the most accurate estimates possible of the associated costs and benefits so that decisionmakers can determine whether and how to proceed. The company agreed with our recommendation and plans on taking corrective action.

This report presents the results of our self-initiated audit of the Efficiency of Operations at the Indianapolis Processing and Distribution Center (P&DC) in Indianapolis, IN (Project Number 22-080). We conducted this audit to provide U.S. Postal Service management with timely information on operational risks at this P&DC. We judgmentally selected the Indianapolis P&DC based on a review of overtime, penalty overtime, late, extra, and cancelled trips by Postal Vehicle Service (PVS) and Highway Contract Route (HCR) drivers, and overall scanning performance. The Indianapolis P&DC is in the Westshores Division and processes letters and flats; and it services multiple 3-digit ZIP Codes in urban and rural communities.

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