Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate OIG identified concerns related to the assessment and documentation practices of a behavioral health certified registered nurse practitioner (BHNP) and leaders’ completion of BHNPs’ ongoing professional practice evaluations (OPPEs) at the VA Pittsburgh Healthcare System (facility) in Pennsylvania. During the inspection, the OIG found that the BHNP did not perform thorough suicide risk assessments for a patient who died by suicide.The OIG identified multiple deficiencies in a BHNP’s assessment and documentation practices including absence of comprehensive suicide risk assessments, failure to complete abnormal involuntary movement and metabolic assessments for patients prescribed certain antipsychotic medication, missing informed consent or a risk-benefit discussion when prescribing off-label medications, failure to resolve rule-out diagnoses, and substantial copy and paste use. The OIG found adverse clinical outcomes for one of eight patients for whom the BHNP did not document a comprehensive suicide risk assessment, as required by The Joint Commission.The OIG concluded that the Nurse Manager evaluated BHNPs as satisfactory in the OPPE elements of copy and paste use for fiscal year 2018 through the first half of fiscal year 2021, and safety plan completion for high risk for suicide patients for February 2020 through the first half of fiscal year 2021, without these elements being evaluated.The OIG made five recommendations to the Facility Director related to a comprehensive review of the BHNP’s assessment practices regarding the patient who died by suicide, a review of the BHNP’s overall assessment and documentation practices, alignment of facility policy and leaders’ expectations related to the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed antipsychotic medications, Behavioral Health managers’ verification of BHNPs’ OPPEs review, and a review of managers’ oversight of BHNPs’ OPPEs.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate leaders’ response to the knowledge of inappropriate provider-patient relationships (inappropriate relationships) in the Mental Health Service Line at the VA Illiana Health Care System (facility) in Danville, Illinois.The OIG determined that while facility leaders took initial actions to address three inappropriate relationships between mental health providers (Providers A, B, and C) and mental health patients (Patients A, B, and C), multiple factors affected the effectiveness of those actions. The OIG found that effective facility leader actions to investigate and address the inappropriate relationships of Provider A and Provider B occurred only after an Office of Accountability and Whistleblower Protection complaint. Facility leaders ineffectively addressed Provider C’s inappropriate relationship before Patient C died by overdose.Facility leaders implemented action plans to prevent future occurrences of inappropriate relationships. Given the egregious nature of the providers’ behaviors, facility leaders failed to report Providers B and C to their state licensing boards in a timely manner and failed to report Provider A to the appropriate professional certification board.The OIG also determined that facility leaders did not take actions to address the circumstances that contributed to the death of Patient C who was involved in an inappropriate romantic relationship with Provider C.The OIG made one recommendation to the Veterans Integrated Service Network 12 Director related to evaluating processes that affected facility supervisors’ identification and actions to address inappropriate relationships. The OIG made two recommendations to the Facility Director related to timely reporting of providers to state licensing or certification boards, and reviewing Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted.

The VA Office of Inspector General (OIG) audited Post-9/11 GI Bill student enrollments that included vacation breaks because of the risk they were not being accurately processed and veterans were not getting the correct benefits.The OIG found the Veterans Benefits Administration (VBA) did not always accurately process these enrollments. An estimated 2,500 of 10,000 enrollments from August 1, 2020, through April 1, 2021, should have been adjusted for vacation breaks but were not.Insufficient training and guidance meant school certifying officials frequently made mistakes. About 790 of the estimated errors involved officials either not reporting or underreporting vacation breaks. VBA claims examiners often mishandled enrollments even when the correct information was submitted. The OIG estimated claims examiners incorrectly processed accurately reported vacation breaks for about 1,700 of 2,500 enrollments with errors.The OIG determined that the estimated 2,500 enrollments with vacation break errors resulted in about 14,400 days of undercharges to students’ entitlement and about $624,000 in underpayments for monthly housing allowance and college fund.VBA officials plan to replace manual reporting and processing of enrollments with an automated system. However, VBA still needs to ensure school certifying officials are entering accurate information.The OIG recommended VBA update guidance and training for certifying officials to ensure a clear understanding of how to calculate and report vacation breaks. Other recommendations included creating procedures for claims examiners to verify information in enrollments flagged for manual processing. Amended enrollments for identified reporting errors should be submitted to VBA for remedial action. Data analysis and record matching can be used to identify enrollments likely to have vacation breaks that have not been properly reported or processed as part of VBA’s quality review process. Finally, VBA should include fields for vacation breaks in automated systems to minimize errors caused by manual data entry.

Starting in May 2021 and ending in March 2022, the GPO OIG sent joint teams of auditors, inspectors, and investigators to better understand the purpose, functioning, and management of the U.S. Government Publishing Office’s (GPO) regional offices.

Review of Federal ARC staff use to report potential conflicts of interest and identified some concerns.

Review of ARC staff use to report potential conflicts of interest and identified some concerns