Federal Reports

This report contains information about recommendations from the OIG's audits, evaluations, reviews, and other reports that the OIG had not closed as of the specified date because it had not determined that the Department of Justice (DOJ) or a non-DOJ federal agency had fully implemented them. The list omits information that DOJ determined to be limited official use or classified, and therefore unsuitable for public release.The status of each recommendation was accurate as of the specified date and is subject to change. Specifically, a recommendation identified as not closed as of the specified date may subsequently have been closed.

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) 6: VA Mid-Atlantic Health Care Network in Durham, North Carolina, 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 VISN’s executive leadership team consisted of the acting Network Director, acting Deputy Network Director, acting Chief Medical Officer, and Chief Nursing Officer, who had worked together for about four months. Additional VISN leaders included the Quality Management Officer and acting Human Resources Officer. Selected survey scores related to employees’ satisfaction indicated that leaders were engaged and promoted a culture where employees felt safe bringing forward issues and concerns. Opportunities appeared to exist to improve employee perceptions of servant leadership and reduce feelings of moral distress in the workplace. Patient experience survey scores were lower than VHA averages.The OIG’s review of access metrics and clinical vacancies identified potential organizational risks at selected facilities, with extended average wait times and clinical vacancies in certain specialties. The executive leaders were knowledgeable within their scope of responsibilities about VHA data and factors contributing to poorly performing quality measures; however, opportunities existed to improve their facility-level oversight of quality, safety, and value; care coordination; and high-risk processes.The OIG issued five recommendations for improvement in three areas:(1) Medical Staff Credentialing• Physician credentials review process(2) Environment of Care• Emergency management committee meetings• Annual review of VISN-wide strengths, weaknesses, priorities, and requirements for improvement(3) Women’s Health• Annual site visits• Staff education gap assessments

The VA Office of Inspector General (OIG) assessed the stewardship and oversight of funds by the Durham VA Health Care System in North Carolina and identified potential cost efficiencies in carrying out medical center functions from October 1, 2020, through March 31, 2021. The healthcare system had 309 inactive obligations totaling $81.7 million. Of these 309 obligations, 200 (totaling over $74 million) had no activity for 181 days or more. In a subsample of 20 obligations, VA staff had not reviewed 17, as required. If inactive obligations are not reviewed, these funds cannot be reobligated and used in that fiscal year to support veterans. The OIG also found that, contrary to VA policy, healthcare system staff used purchase cards instead of contracts for 21 of 40 sampled transactions (53 percent), totaling approximately $328,000. These 21 transactions were missing required supporting documentation to verify that the transactions were approved and payments were accurate, resulting in $308,000 in questioned costs. Furthermore, the purchase card coordinator did not conduct required quarterly audits. The healthcare system had 105 more administrative full time equivalent staff than the expected number, which suggests the potential opportunity to improve efficiency. The healthcare system could improve pharmacy efficiency by narrowing the gap between the facility’s observed drug costs and expected drug costs, bringing the turnover rates closer to the Veterans Health Administration–recommended level, and meeting requirements for noncontrolled drug line audits. The OIG made nine recommendations to the healthcare system director and one recommendation to the director of contracting for Network Contracting Office 6, VA Mid-Atlantic Health Care Network.

SB & Company found that the lack of off-site data backups increases the CSB’s risk of losing significant data.

We conducted a limited review of nursing home owners to identify their operational challenges and needs of nursing homes in responding to the Coronavirus Disease 2019 (COVID-19) pandemic. Our objective was to determine the biggest challenges operators of Section 232 nursing home facilities face related to the COVID-19 pandemic and whether nursing homes are prepared to meet their future financial obligations. Most of the owners who responded to our survey indicated that nursing homes experienced financial and operational challenges during the pandemic. These challenges included staffing shortages; COVID-19 infections in residents and staff; large fluctuations in occupancy levels; rising operating costs; and difficulties in responding to local, State, and Federal requirements.