Clinical Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama for Thursday, 1 June 2017 - Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States
Veterans Affairs Office of Inspector General (OIG).
The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Birmingham VA Medical Center. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. During the review, OIG provided crime awareness briefings to 638 employees. OIG identified certain system weaknesses in in credentialing and privileging, utilization management, environmental cleanliness, transfer documentation, Community Nursing Home Oversight Committee representation and annual reviews, and disruptive/violent behavior documentation and employee training. As a result of the findings, OIG could not gain reasonable assurance that the facility: (1) Reviews credentialing and privileging documentation and documents utilization management decisions; (2) Maintains clean floors in in the coronary care, hospitalist (6B), and medical intensive care units and the dental clinic and stores sharps containers in a manner that prevents the potential spread of infection; (3) Transfers all patients from the facility safely; (4) Effectively oversees the community nursing home program (5) Notifies patients about flagging their health records for violent/disruptive behavior, approves Orders for Behavioral Restriction appropriately, and trains employees to reduce and prevent disruptive behaviors. OIG made recommendations for improvement in the following five review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Coordination of Care: Inter-Facility Transfers; (4) Community Nursing Home Oversight; and (5) Management of Disruptive/Violent Behavior.
Veterans Affairs Office of Inspector General (OIG)
801 I Street NorthWest
Washington, D.C. 20536, United States
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The VA Office of Inspector General (OIG) conducted an evaluation of the quality of care provided in the inpatient and outpatient settings of the Birmingham VA Medical Center. This included reviews of various aspects of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. During the review, OIG provided crime awareness briefings to 638 employees. OIG identified certain system weaknesses in in credentialing and privileging, utilization management, environmental cleanliness, transfer documentation, Community Nursing Home Oversight Committee representation and annual reviews, and disruptive/violent behavior documentation and employee training. As a result of the findings, OIG could not gain reasonable assurance that the facility: (1) Reviews credentialing and privileging documentation and documents utilization management decisions; (2) Maintains clean floors in in the coronary care, hospitalist (6B), and medical intensive care units and the dental clinic and stores sharps containers in a manner that prevents the potential spread of infection; (3) Transfers all patients from the facility safely; (4) Effectively oversees the community nursing home program (5) Notifies patients about flagging their health records for violent/disruptive behavior, approves Orders for Behavioral Restriction appropriately, and trains employees to reduce and prevent disruptive behaviors. OIG made recommendations for improvement in the following five review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Coordination of Care: Inter-Facility Transfers; (4) Community Nursing Home Oversight; and (5) Management of Disruptive/Violent Behavior.
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Opioid Management Practice Concerns, John J. Pershing VA Medical Center Popular Bluff, Missouri for Thursday, 1 June 2017 - Veterans Affairs Office in Washington, D.C., United States
Veterans Affairs Office of Inspector General (OIG).
OIG conducted an inspection to evaluate allegations regarding opioid management practices at the John J. Pershing VA Medical Center (facility), Poplar Bluff, MO. Allegations included: Long-term opioid therapy for pain was poorly managed for certain patients; Opioid prescriptions were written for patients without documentation of an opioid risk stratification tool, such as the opioid risk tool (ORT); Some providers did not consistently use urine drug screening (UDS), order confirmatory tests to evaluate for diversion, or further evaluate UDS results that were suggestive of urine tampering; and Opioid pain care agreements, including signed informed consents, were not consistently completed prior to initiating long-term opioid therapy for pain. We substantiated poor management of long-term opioid pain therapy for 10 patients. We found documentation for the condition requiring opioid therapy but did not find risk evaluation when clinically significant changes to a patient’s health status occurred. We found that a provider lacked knowledge of safe and effective methods for tapering patients’ opioids. We substantiated that opioid prescriptions were written for patients without documentation of an opioid risk stratification tool such as ORT. The Veterans Health Administration’s Opioid Safety Initiative provides guidelines to develop tools to identify high-risk patients. Using the ORT helps a provider risk stratify patients for initiating or continuing opioid therapy, and the ORT can help guide providers in determining the frequency of obtaining UDS for patients on long-term opioid therapy for pain. We substantiated that some providers did not consistently use UDS, order confirmatory tests to evaluate for diversion, or further evaluate UDS results that were suggestive of urine tampering for the patients reviewed. We substantiated that some patients did not have signed informed consents prior to initiating long-term opioid therapy for pain. We recommended that the Facility Director ensure that relevant providers complete timely patient evaluations; receive education on dual short acting opioids and tapering of opioids; review Veterans Health Administration recommendations regarding the use of opioid risk stratification tools; order UDS frequency based on risk assessment and complete UDS at least annually; consistently use UDS confirmatory testing; and consistently complete the informed consent process prior to initiating long-term opioid therapy for pain. We also recommended that the Facility Director ensure that reviews of the identified patients’ cases are completed and develop processes to minimize the potential for UDS tampering.
Veterans Affairs Office of Inspector General (OIG)
801 I Street NorthWest
Washington, D.C. 20536, United States
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OIG conducted an inspection to evaluate allegations regarding opioid management practices at the John J. Pershing VA Medical Center (facility), Poplar Bluff, MO. Allegations included: Long-term opioid therapy for pain was poorly managed for certain patients; Opioid prescriptions were written for patients without documentation of an opioid risk stratification tool, such as the opioid risk tool (ORT); Some providers did not consistently use urine drug screening (UDS), order confirmatory tests to evaluate for diversion, or further evaluate UDS results that were suggestive of urine tampering; and Opioid pain care agreements, including signed informed consents, were not consistently completed prior to initiating long-term opioid therapy for pain. We substantiated poor management of long-term opioid pain therapy for 10 patients. We found documentation for the condition requiring opioid therapy but did not find risk evaluation when clinically significant changes to a patient’s health status occurred. We found that a provider lacked knowledge of safe and effective methods for tapering patients’ opioids. We substantiated that opioid prescriptions were written for patients without documentation of an opioid risk stratification tool such as ORT. The Veterans Health Administration’s Opioid Safety Initiative provides guidelines to develop tools to identify high-risk patients. Using the ORT helps a provider risk stratify patients for initiating or continuing opioid therapy, and the ORT can help guide providers in determining the frequency of obtaining UDS for patients on long-term opioid therapy for pain. We substantiated that some providers did not consistently use UDS, order confirmatory tests to evaluate for diversion, or further evaluate UDS results that were suggestive of urine tampering for the patients reviewed. We substantiated that some patients did not have signed informed consents prior to initiating long-term opioid therapy for pain. We recommended that the Facility Director ensure that relevant providers complete timely patient evaluations; receive education on dual short acting opioids and tapering of opioids; review Veterans Health Administration recommendations regarding the use of opioid risk stratification tools; order UDS frequency based on risk assessment and complete UDS at least annually; consistently use UDS confirmatory testing; and consistently complete the informed consent process prior to initiating long-term opioid therapy for pain. We also recommended that the Facility Director ensure that reviews of the identified patients’ cases are completed and develop processes to minimize the potential for UDS tampering.
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Review of Alleged Mismanagement of VA's Human Resources and Administration Contract Funds for Thursday, 1 June 2017 - Veterans Affairs Office of Inspector General (OIG in Washington, D.C., United States
Veterans Affairs Office of Inspector General (OIG).
In September 2015, the Office of Inspector General received an allegation that the Office of Human Resources and Administration’s (HR&A) VA Learning University (VALU) management authorized vendor payment for a Dashboard Tool before receiving the deliverable. In addition, the complainant alleged HR&A provided a competitive advantage to a vendor by helping the vendor develop a performance work statement for a future contract to maintain the Dashboard Tool. The Dashboard Tool is a web-based interface designed to organize and manage HR&A and VALU program data, such as performance metrics and training outcomes. We substantiated the allegation that VALU management authorized final payment in April 2015 for the Dashboard Tool that had not been delivered. We determined VALU did not accept the Dashboard Tool because it did not have the capability to operate the tool. Authorizing final payment before delivery did not allow VA to determine whether the Dashboard Tool conformed to applicable contract quality requirements. The former Dean of VALU did not assign responsibility for identifying and procuring a hosting solution to any individual or office. The former Dean also did not take timely action to obtain about $3,200 in funding to purchase a hosting solution. As a result, HR&A was unable to use its estimated $3.7 million investment in the Dashboard Tool. As of March 2017, HR&A had not purchased a hosting solution on which to operate the Dashboard Tool. The Dashboard Tool remained in the possession of the vendor. We did not substantiate the allegation that HR&A provided a competitive advantage to a vendor for a future contract to maintain the Dashboard Tool. We found that HR&A officials drafted a performance work statement for a Dashboard Tool maintenance contract. An Office of Acquisition Operations contracting officer appropriately refused to approve the performance work statement determining the contract was unnecessary because VALU officials could not demonstrate that they were in possession of the Dashboard Tool. We recommended the Acting Assistant Secretary for HR&A assign responsibility to assess hosting solution options for the Dashboard Tool, and evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool. The Acting Assistant Secretary for HR&A concurred with our recommendations. We consider Recommendation 1 closed and will follow up on the implementation of the remaining recommendation.
Veterans Affairs Office of Inspector General (OIG)
801 I Street NorthWest
Washington, D.C. 20536, United States
In September 2015, the Office of Inspector General received an allegation that the Office of Human Resources and Administration’s (HR&A) VA Learning University (VALU) management authorized vendor payment for a Dashboard Tool before receiving the deliverable. In addition, the complainant alleged HR&A provided a competitive advantage to a vendor by helping the vendor develop a performance work statement for a future contract to maintain the Dashboard Tool. The Dashboard Tool is a web-based interface designed to organize and manage HR&A and VALU program data, such as performance metrics and training outcomes. We substantiated the allegation that VALU management authorized final payment in April 2015 for the Dashboard Tool that had not been delivered. We determined VALU did not accept the Dashboard Tool because it did not have the capability to operate the tool. Authorizing final payment before delivery did not allow VA to determine whether the Dashboard Tool conformed to applicable contract quality requirements. The former Dean of VALU did not assign responsibility for identifying and procuring a hosting solution to any individual or office. The former Dean also did not take timely action to obtain about $3,200 in funding to purchase a hosting solution. As a result, HR&A was unable to use its estimated $3.7 million investment in the Dashboard Tool. As of March 2017, HR&A had not purchased a hosting solution on which to operate the Dashboard Tool. The Dashboard Tool remained in the possession of the vendor. We did not substantiate the allegation that HR&A provided a competitive advantage to a vendor for a future contract to maintain the Dashboard Tool. We found that HR&A officials drafted a performance work statement for a Dashboard Tool maintenance contract. An Office of Acquisition Operations contracting officer appropriately refused to approve the performance work statement determining the contract was unnecessary because VALU officials could not demonstrate that they were in possession of the Dashboard Tool. We recommended the Acting Assistant Secretary for HR&A assign responsibility to assess hosting solution options for the Dashboard Tool, and evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool. The Acting Assistant Secretary for HR&A concurred with our recommendations. We consider Recommendation 1 closed and will follow up on the implementation of the remaining recommendation.
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Men’s Health Month: Making smart choices every day, all year long for Thursday, 1 June 2017 - Military Health System in Washington, D.C., United States
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Military Health System
The Pentagon
Washington, D.C., 20301 United States
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