Federal Reports

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Networks (VISNs) 2, 5, and 6 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISNs 2, 5, and 6 vaccination efforts.The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure information is provided in a comprehensive manner, given the changing landscape as infection rates and demands on facilities continue to shift. Findings of inspected medical facilities are grouped by VISN, which are regional systems that provide oversight of medical centers in their area.This report, the fourth in a series, describes findings on COVID-19 practices from healthcare inspections performed within VISNs 2, 5, and 6 during the third and fourth quarters of fiscal year 2021 (April 1 through September 30, 2021). It provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of September 2021. Additionally, it includes information on COVID-19 vaccination efforts, based on a review of VA’s vaccination statistics as of September 29, 2021. Interviews and survey results provide additional context on lessons learned and perceptions of readiness and response.This report aims to provide the nation’s largest integrated healthcare system with relevant information to use in its efforts toward innovation and transformation to meet the healthcare needs of our nation’s veterans.

Prior to landing humans on the Moon as part of the Artemis program, NASA is developing new science instruments to explore the lunar surface including VIPER, a rover that will survey the Moon’s water ice to see if people can “live off the land.” In this report, we assessed NASA’s management of the VIPER project.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the VA Western New York Healthcare System. The inspection covered key clinical and administrative processes that are associated with promoting quality care. It focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Registered Nurse Credentialing; Medication Management: Remdesivir Use in VHA; Mental Health: Emergency Department and Urgent Care Center Suicide Risk Screening and Evaluation; Care Coordination: Inter-facility Transfers; and High-Risk Processes: Management of Disruptive and Violent Behavior.The healthcare system’s executive leadership team appeared stable, with all positions permanently assigned. Leaders had worked together for about five months, although some had served in their positions for multiple years. Employee survey data revealed opportunities for leaders to improve workplace satisfaction and reduce feelings of moral distress. Patients generally appeared satisfied with their care. The inspection team reviewed accreditation agency findings and disclosures of adverse patient events and did not identify substantial organizational risk factors. However, the OIG identified concerns related to sentinel event identification and reporting. Executive leaders were generally knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and should continue to take actions to sustain and improve performance.The OIG issued seven recommendations for improvement in four areas:(1) Leadership and Organizational Risks• Identification and reporting of sentinel events(2) Quality, Safety, and Value• Peer review committee recommendation of improvement actions• Surgical work group attendance(3) Care Coordination• Monitoring and evaluation of inter-facility transfers(4) High-Risk Processes• Disruptive behavior committee meeting attendance• Staff training

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Linda Vista Station, San Diego, CA (Project Number 22-059). The Linda Vista Station is in the California District of the WestPac Area and services ZIP Codes 92108 and 92111. These ZIP Codes serve about 65,493 people and are considered to be urban communities. We judgmentally selected the Linda Vista Station based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Ramona Main Post Office (MPO) in Ramona, CA (Project Number 22-062). The Ramona Main Post Office is in the California 6 District of the WestPac Area and services ZIP Code 92065, which serves about 35,349 people and is considered to be an urban community. We judgmentally selected the Ramona MPO based on the number of stop-the-clock (STC) scans occurring at the delivery unit, rather than at the customer’s delivery address.

This interim report presents the results of our self-initiated audit of mail delivery, customer service, and property conditions at the Downtown San Diego Station in San Diego, CA (Project Number 22-060). The Downtown San Diego Station is in the California District of the WestPac Area. The station services ZIP Code 92101, which serves about 36,785 people and is considered an urban community. We judgmentally selected the Downtown San Diego Station based on the number of stop-the-clock (STC)3 scans occurring at the delivery unit, rather than at the customer’s delivery address.