Federal Reports

The OIG found approximately half of the DNFSB’s planned Review Agendas for Fiscal Years 2019 through 2024 were carryovers from prior years.  Some of these carryover reviews were delayed, and in those cases, justifications for delays were not consistently recorded.  Moreover, the OIG found that the DNFSB does not have a structured Knowledge Management Program, and DNFSB Review Agenda guidance is not aligned with its current process.

The report contains three recommendations to update and improve the agency’s Review Agenda process.  

The audit objectives were to determine whether program funds were managed in accordance with the ARC and Federal grant requirements.

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA New Mexico Healthcare System (facility) to assess allegations and concerns related to the care of a patient who was labeled as ineligible for care and senior leaders’ associated response.

In early 2024, the patient was admitted to the facility and applied for healthcare benefits. The patient inaccurately reported income on the application, and benefits were declined. Social work staff, aware of the inaccuracies, did not ensure information was corrected. Additionally, staff attempted to arrange post-hospital services only available to eligible patients and failed to coordinate follow-up care after discharge.

In spring 2024, the patient returned to the facility, was admitted, and then discharged the same day due to being labeled as ineligible for care. The OIG did not substantiate that a podiatrist was forced to discharge the patient. However, knowledge and communication deficits contributed to the following deficiencies:
•    The emergency department provider did not follow stated practice to transfer or admit the patient. 
•    Staff missed another opportunity to update the patient’s financial information.
•    The podiatrist did not seek Chief of Staff approval to continue care at the facility or transfer the patient to a community hospital.
•    Staff did not provide an adequate discharge plan. Instead, the patient was left alone on a bench to await ambulance transport and did not receive written discharge instructions.
•    The podiatrist did not contact the community hospital to share information.
•    The nurse officer of the day failed to address a nurse’s attempt to escalate concerns.

The OIG found senior leaders did not effectively use root cause analysis processes or apply High Reliability Organization principles to assess the spring 2024 discharge. First-year podiatry residents were not supervised according to Veterans Health Administration policy.

The OIG made 15 recommendations to the Facility Director.