Federal Reports

The U.S. Postal Service’s International Service Center in San Francisco, CA (SFO ISC) houses select international and military mail processing functions and a retail unit. In April 2020, the lessor notified the Postal Service that they were discontinuing the facility lease and subsequent discussions about potential on-airport facility alternatives proved unsuccessful. As a result, the Postal Service decided to permanently relocate processing operations to local and regional facilities and temporarily suspend retail services, steering customers to nearby post offices pending a final Postal Service decision on the unit. This report responds to a September 2021 congressional request regarding closure of the SFO ISC.

The tribal official profited from awarding contracts that resulted in his company receiving subcontracts, but no policy prohibited his actions.

OIG performed a review to assess whether the Peace Corps complied with the PIIA reporting requirements and provided adequate disclosure within the annual AFR and accompanying materials. In addition, we also evaluated the accuracy and completeness of the agency’s reporting. Our review determined that the Peace Corps was compliant with PIIA for Fiscal Year (FY) 2021.

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.