OIG Monthly Highlights
CONGRESSIONAL TESTIMONY
INSPECTOR GENERAL TESTIFIES BEFORE SENATE APPROPRIATORS AT HEARING FOCUSED ON PREVENTING OPIOID OVERMEDICATION OF VETERANS
Inspector General Missal testified before the U.S. Senate Committee on Appropriations’ Subcommittee on Military Construction, Veterans Affairs, and Related Agencies. The testimony focused on the findings and recommendations from the Office of Inspector General’s (OIG) recent report, Healthcare Inspection—Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care. Mr. Missal acknowledged that VA has made some significant steps in battling the opioid crisis, but noted there is much more work to be done. He explained that health information sharing between VA and non-VA providers has been a significant problem throughout the history of the Veterans Health Administration’s purchased care programs. With respect to the Veterans Choice Program, the OIG found that a significant risk exists for patients who are prescribed opioid prescriptions outside of VA. Specifically, gaps in health information exchanges between VA and non-VA providers can put certain patients at significant risk for serious medication interaction and overdose. Those especially at risk include patients suffering from chronic pain and mental illness who receive opioid prescriptions from non-VA clinical settings where opioid prescribing and monitoring guidelines may conflict with VA guidelines. To close this gap and improve care coordination between VA and non-VA providers, the OIG made four recommendations: (1) requiring that all non-VA providers receive and review VA’s opioid prescribing guidelines, (2) implementing a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history, (3) requiring non-VA providers to submit opioid prescriptions directly to a VA pharmacy, and (4) ensuring that VA takes immediate action if a non-VA provider’s opioid prescribing practices are determined to be in conflict with Opioid Safety Initiative guidelines. Mr. Missal stressed that the issues raised in his testimony and in the OIG’s report merit serious consideration as Congress and VA work together to revamp Choice.
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"Healthcare Inspection – Patient Mental Health Care Issues at a Veterans Integrated Service Network 16 Facility" Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States
Healthcare Inspection – Patient Mental Health Care Issues at a Veterans Integrated Service Network 16 Facility
OIG conducted a healthcare inspection to assess the merit of allegations from a complainant about mental health care provided to a patient at a Veterans Integrated Service Network 16 facility, prior to his suicide. We substantiated that the patient had been reasonably stable on his medication regimen, including clonazepam, for many years and that the patient was not placed back on his preferred medication (clonazepam) by psychiatrists despite his requests to do so. We substantiated that the patient was not admitted to the psychosocial residential rehabilitation treatment program and identified several barriers to the patient’s admission including misconceptions about admission criteria, delays in tuberculosis testing, poor communication between providers, and delays in contacting the patient. We found that, contrary to Veterans Health Administration (VHA) policy, the patient’s treatment preferences were not considered, nor was the patient informed of his right to appeal treatment decisions made by mental health staff. Furthermore, refusal on the part of the patient’s psychiatrist to treat the patient unless he agreed to not taking clonazepam created a treatment impasse and violated VHA policy. We found that because of limited availability of psychiatry appointments, the patient did not have timely access to mental health care after his discharges from community psychiatric hospitals and as his mental health condition worsened, other care options, such as Non-VA care, were not explored. We found that communication and planning by the patient’s mental health providers was not commensurate with the patient’s needs. In spite of the patient’s deteriorating mental health condition, multiple suicide attempts, and frequent hospitalizations, his underlying bipolar disease was not adequately treated, and ultimately, his poorly controlled mood disorder was the likely underlying cause for the patient’s suicidal thinking. We made 12 recommendations.
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"Comprehensive Healthcare Inspection Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico" Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States
Comprehensive Healthcare Inspection Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico
The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the New Mexico VA Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG provided crime awareness briefings to 33 employees. The facility has generally stable executive leadership to support patient safety, quality care, and other positive outcomes. However, the presence of organization risk factors, as evidenced by sentinel events, disclosures, and Patient Safety Indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Facility leaders should continue to take actions to improve performance of selected Strategic Analytics for Improvement and Learning metrics, particularly Quality of Care and Efficiency metrics. OIG noted findings in the six areas of clinical operations reviewed and issued 20 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, Associate Director, and Assistant Director. The identified areas with deficiencies are: (1) Quality, Safety, and Value • Ongoing Professional Practice Evaluation data review • Utilization management documentation (2) Medication Management: Anticoagulation Therapy • Quality assurance data review • Patient education • Required laboratory tests • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers • Transfer data analysis and reporting • Patient transfer documentation • Communication with accepting facility (4) Environment of Care • Environment of care rounds frequency and attendance • General cleanliness • Outdated supplies • Physical security risk assessment • Mental health unit employee and inspection team training (5) High-Risk Processes: Moderate Sedation • Informed consent • Timeout participation and checklist (6) Long-Term Care: Community Nursing Home Oversight • Oversight committee representation • Monthly clinical visits
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"Healthcare Inspection – Alleged Women’s Health Care Issues, Gulf Coast Veterans Health Care System, Biloxi, Mississippi" Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States
Healthcare Inspection – Alleged Women’s Health Care Issues, Gulf Coast Veterans Health Care System, Biloxi, Mississippi
OIG conducted an inspection in response to allegations regarding gynecology and women’s health primary care services at the VA Gulf Coast Veterans Health Care System (system), Biloxi, MS. Specifically, the allegations were that a system gynecologist turned away patients by cancelling their consults for routine cancer screenings; did not order the correct test for a patient who was contemplating a hysterectomy; refused to perform two tubal ligations; refused to reorder medications for a patient; failed to document gynecology procedures correctly; and failed to use a colposcope to perform colposcopies. Additional allegations were that a Women’s Health Clinic physician assistant was not addressing a patient’s medical care and that system gynecologists lived too far away to be on-call for surgical patients. We did not substantiate the above allegations, except that a system gynecologist did not reorder a medication for another gynecologist’s patient. However, we determined that it was reasonable for the covering gynecologist to defer reordering to the regular gynecologist. During the inspection, we identified several issues under the responsibility of medical leadership: providers did not always follow Veterans Health Administration (VHA) cervical cancer screening guidelines; loop electrosurgical excision procedures were performed in the operating room with general anesthesia; communication and collaboration was lacking between gynecologists and providers and between providers and patients that may have affected safe and effective patient care; a care coordination agreement was outdated; and one gynecologist’s privileges were not in compliance with system required experience to perform surgical procedures. We also found that the Patient Advocacy Program, under the responsibility of system leadership, was not tracking complaints as required by VHA. We made six recommendations.
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"Administrative Investigation – Improper Relocation Allowance and Market Pay, Veterans Health Administration, Washington, DC" Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States
Administrative Investigation – Improper Relocation Allowance and Market Pay, Veterans Health Administration, Washington, DC
The VA Office of Inspector General Administrative Investigations Division received an allegation that Dr. Gavin West, former (reassigned) Senior Medical Advisor to Dr. Thomas Lynch, Assistant Deputy Under Secretary for Health (ADUSH) for Clinical Operations, and a former (resigned) VA employee misused VA travel funds for personal rather than official business. We did not substantiate the allegation of a misuse of VA travel funds, and we will not discuss it further in this report. In reviewing Dr. West’s personnel records related to the original allegation, we found that Dr. West was improperly paid $19,800 for Temporary Quarters Subsistence Expenses (TQSE) in connection with a Permanent Change of Station (PCS) move that he did not execute. The TQSE was paid to Dr. West to relocate from his then duty station in Salt Lake City, UT to Washington, DC, after accepting a position as the Special Assistant to the ADUSH for Clinical Operations on September 22, 2013. Dr. West did not relocate nor did he repay VA for the TQSE. We also found that his annual salary was increased from $188,049 to $206,527 to make his “salary competitive with the market rate in the Washington DC Metro geographical region.” Because he did not relocate, this resulted in overpayments to Dr. West of over $55,000.
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"Administrative Investigation – Improper Locality Pay, Office of the General Counsel, Pacific District South, Phoenix, Arizona" Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States
Administrative Investigation – Improper Locality Pay, Office of the General Counsel, Pacific District South, Phoenix, Arizona
On March 2, 2017, the VA Office of Inspector General Administrative Investigations Division received allegations that Ms. [redacted] , former (resigned) Deputy Counsel, Office of the General Counsel (OGC), improperly received the higher locality pay for Los Angeles, CA, while she lived and worked in Phoenix, AZ. We found that Ms. [redacted] received about $6,500 in Los Angeles locality pay for 6 months while residing and reporting for duty in Phoenix.
Veterans Affairs Office of Inspector General (OIG)
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