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Veterans Experience Office
Department of Veterans Affairs
If you wish to share your feedback, please do so by August 14, 2017 at 11:37 PM
Department of Veterans Affairs
Veterans Experience Office (30)
810 Vermont Avenue, North West
Washington, D.C. 20420, United States
-------Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States for Tuesday, 1 August 2017 "Clinical Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina"
Clinical Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina
The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the W.G. (Bill) Hefner VA Medical Center. This included reviews 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 (CNH) Oversight; Management of Disruptive/Violent Behavior; and Mental Health Residential Rehabilitation Treatment Program (MH RRTP). OIG provided crime awareness briefings to 71 employees. OIG identified certain system weaknesses in utilization management, general safety, environmental cleanliness, anticoagulation patient education, transfer documentation, glucometer quality control testing, moderate sedation processes and documentation, CNH oversight and clinical visits, disruptive/violent behavior documentation and employee training, and MH RRTP inspections and environmental safety. As a result of the findings, OIG could not gain reasonable assurance that the facility: (1) Has effective documentation, communication, and quality improvement processes for decisions involving utilization management; (2) Maintains a clean environment of care in the Emergency Department and has a policy and procedure for the reprocessing of reusable medical equipment; (3) Maintains a safe environment of care with consistent fire drills, labels food items in the nourishment refrigerators, and secures chemicals in the hemodialysis unit; (4) Provides effective anticoagulation therapy management patient education; (5) Has a safe inter-facility transfer process; (6) Performs quality control testing on glucometers; (7) Provides safe moderate sedation care; (8) Provides effective CNH oversight; (9) Has an effective process for the management of disruptive/violent behavior; (10) Maintains a safe MH RRTP environment. OIG made recommendations for improvement in the following nine review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Coordination of Care; (5) Diagnostic Care; (6) Moderate Sedation; (7) CNH Oversight; (8) Management of Disruptive/Violent Behavior; and (9) MH RRTP.
Veterans Affairs Office of Inspector General (OIG).
Veterans Affairs Office of Inspector General (OIG)
801 I Street North West
Washington, D.C. 20536, United States
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Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States for Tuesday, 1 August 2017 "Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC"
Veterans Affairs Office of Inspector General (OIG).
Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC
VA OIG Administrative Investigations Division issued a report titled: Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC
Veterans Affairs Office of Inspector General (OIG).
Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States for Tuesday, 1 August 2017 "Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC"
Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC
VA OIG Administrative Investigations Division issued a report titled: Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC
Veterans Affairs Office of Inspector General (OIG).
Veterans Affairs Office of Inspector General (OIG)
801 I Street North West
Washington, D.C. 20536, United States
-------Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States for Tuesday, 1 August 2017 "Inspection of the Veterans Service Center Cheyenne, Wyoming"
Veterans Affairs Office of Inspector General (OIG).
Inspection of the Veterans Service Center Cheyenne, Wyoming
In February 2017, OIG evaluated the Cheyenne, WY Veterans Service Center (VSC) to determine how well VSC staff processed disability claims, how timely and accurately they processed proposed rating reductions, how accurately they entered claims-related information, and how well they responded to special controlled correspondence. The Cheyenne VSC is under the jurisdiction of the Denver VA Regional Office (VARO). Generally, VSC staff accurately processed the two types of disability claims we reviewed. We reviewed 30 of 121 veterans’ traumatic brain injury (TBI) claims (25 percent) and found that VSC staff accurately processed 29 cases (97 percent). These errors identified do not represent the universe of disability claims or the overall accuracy rate at this VSC. We also reviewed two veterans’ claims involving entitlement to special monthly compensation (SMC) and related ancillary benefits completed by VSC staff from January 1 through December 31, 2016. We determined that VSC staff processed both claims accurately. We did not identify any claims processing errors that affected veterans’ benefits. VSC staff generally processed proposed rating reductions accurately and timely. OIG reviewed 11 rating reductions cases and found that VSC staff accurately processed all 11 cases and timely processed nine of the 11 cases (82 percent). VSC staff needed to improve the accuracy of claims-related information input into the electronic systems at the time of claims establishment. OIG reviewed 30 of 199 newly established claims (15 percent) and found that VSC staff did not correctly input claim information into the electronic system in 24 cases (80 percent). This occurred because of a lack of training; specifically, staff did not receive training on claims establishment procedures and proper dates of claims when in receipt of reexamination reminder notifications. Furthermore, supervisors did not perform quality reviews for claims processing staff. VSC staff generally provided complete and timely responses to special controlled correspondence. OIG reviewed 19 special controlled correspondence and found that VSC staff accurately processed 16 cases (84 percent) and timely processed 18 cases (95 percent). OIG recommended the VARO Director provide training on the proper procedures for inputting dates of claim for system-generated notifications and ensure monthly quality reviews are performed for all employees who establish veterans’ claims. The VARO Director concurred with our recommendations. Management’s planned actions are responsive. OIG will follow up as required.
Veterans Affairs Office of Inspector General (OIG).
Inspection of the Veterans Service Center Cheyenne, Wyoming
In February 2017, OIG evaluated the Cheyenne, WY Veterans Service Center (VSC) to determine how well VSC staff processed disability claims, how timely and accurately they processed proposed rating reductions, how accurately they entered claims-related information, and how well they responded to special controlled correspondence. The Cheyenne VSC is under the jurisdiction of the Denver VA Regional Office (VARO). Generally, VSC staff accurately processed the two types of disability claims we reviewed. We reviewed 30 of 121 veterans’ traumatic brain injury (TBI) claims (25 percent) and found that VSC staff accurately processed 29 cases (97 percent). These errors identified do not represent the universe of disability claims or the overall accuracy rate at this VSC. We also reviewed two veterans’ claims involving entitlement to special monthly compensation (SMC) and related ancillary benefits completed by VSC staff from January 1 through December 31, 2016. We determined that VSC staff processed both claims accurately. We did not identify any claims processing errors that affected veterans’ benefits. VSC staff generally processed proposed rating reductions accurately and timely. OIG reviewed 11 rating reductions cases and found that VSC staff accurately processed all 11 cases and timely processed nine of the 11 cases (82 percent). VSC staff needed to improve the accuracy of claims-related information input into the electronic systems at the time of claims establishment. OIG reviewed 30 of 199 newly established claims (15 percent) and found that VSC staff did not correctly input claim information into the electronic system in 24 cases (80 percent). This occurred because of a lack of training; specifically, staff did not receive training on claims establishment procedures and proper dates of claims when in receipt of reexamination reminder notifications. Furthermore, supervisors did not perform quality reviews for claims processing staff. VSC staff generally provided complete and timely responses to special controlled correspondence. OIG reviewed 19 special controlled correspondence and found that VSC staff accurately processed 16 cases (84 percent) and timely processed 18 cases (95 percent). OIG recommended the VARO Director provide training on the proper procedures for inputting dates of claim for system-generated notifications and ensure monthly quality reviews are performed for all employees who establish veterans’ claims. The VARO Director concurred with our recommendations. Management’s planned actions are responsive. OIG will follow up as required.
Veterans Affairs Office of Inspector General (OIG).
Veterans Affairs Office of Inspector General (OIG)
801 I Street North West
Washington, D.C. 20536, United States
-------Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States for Tuesday, 1 August 2017 "Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care"
Veterans Affairs Office of Inspector General (OIG).
Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care
OIG conducted a healthcare inspection to review opioid prescribing to high-risk veterans receiving VA purchased care. VHA developed two initiatives in 2014 to improve the safety and management of chronic pain in veterans: the Opioid Safety Initiative (OSI), and the enabling of VA providers to participate in state prescription drug monitoring programs (PDMP). The OSI includes specific management guidelines including a prescriber’s toolkit and alternative therapeutic approaches to chronic pain. PDMPs are used to track the prescribing and dispensing of controlled substance prescriptions to patients. VA implemented purchased care programs for veterans to access care in the community when necessary, including the Veterans Choice Program. We determined that with the expansion of community partnerships, a significant risk exists for patients prescribed opioid prescriptions outside of VA. Patients with chronic pain and mental health illness who receive opioid prescriptions from non-VA clinical settings where opioid prescribing and monitoring guidelines conflict with VA guidelines may be especially at risk. The risk is exacerbated when information about opioid prescriptions is not shared. Because of challenges related to health information sharing, we noted that non-VA providers do not consistently have access to critical health care information regarding veterans they are treating. We noted that while the ability to query PDMP databases is available, VA providers would not likely access the PDMP when not prescribing controlled substances. Timely notification of veteran patients receiving non-VA opioid prescriptions would allow more immediate VA provider awareness and action, if action were required. If all routine non-VA opioid prescriptions were submitted directly to VA pharmacies, VA pharmacy staff could alert the VA provider that a non-VA opioid prescription was dispensed. This would also allow the same level of pain management committee oversight by VA of opioid prescriptions prescribed by VA and non-VA providers. We recommended the Acting Under Secretary for Health: Require all participating VA purchased care providers receive and review the OSI evidence-based guidelines for prescribing opioids; Implement a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history; Require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing and recording in the patient’s VA electronic health record; Ensure that if facility leaders determine that a non-VA provider’s opioid prescribing practices are in conflict with OSI guidelines, immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider.
Veterans Affairs Office of Inspector General (OIG).
Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care
OIG conducted a healthcare inspection to review opioid prescribing to high-risk veterans receiving VA purchased care. VHA developed two initiatives in 2014 to improve the safety and management of chronic pain in veterans: the Opioid Safety Initiative (OSI), and the enabling of VA providers to participate in state prescription drug monitoring programs (PDMP). The OSI includes specific management guidelines including a prescriber’s toolkit and alternative therapeutic approaches to chronic pain. PDMPs are used to track the prescribing and dispensing of controlled substance prescriptions to patients. VA implemented purchased care programs for veterans to access care in the community when necessary, including the Veterans Choice Program. We determined that with the expansion of community partnerships, a significant risk exists for patients prescribed opioid prescriptions outside of VA. Patients with chronic pain and mental health illness who receive opioid prescriptions from non-VA clinical settings where opioid prescribing and monitoring guidelines conflict with VA guidelines may be especially at risk. The risk is exacerbated when information about opioid prescriptions is not shared. Because of challenges related to health information sharing, we noted that non-VA providers do not consistently have access to critical health care information regarding veterans they are treating. We noted that while the ability to query PDMP databases is available, VA providers would not likely access the PDMP when not prescribing controlled substances. Timely notification of veteran patients receiving non-VA opioid prescriptions would allow more immediate VA provider awareness and action, if action were required. If all routine non-VA opioid prescriptions were submitted directly to VA pharmacies, VA pharmacy staff could alert the VA provider that a non-VA opioid prescription was dispensed. This would also allow the same level of pain management committee oversight by VA of opioid prescriptions prescribed by VA and non-VA providers. We recommended the Acting Under Secretary for Health: Require all participating VA purchased care providers receive and review the OSI evidence-based guidelines for prescribing opioids; Implement a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history; Require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing and recording in the patient’s VA electronic health record; Ensure that if facility leaders determine that a non-VA provider’s opioid prescribing practices are in conflict with OSI guidelines, immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider.
Veterans Affairs Office of Inspector General (OIG).
Veterans Affairs Office of Inspector General (OIG)
801 I Street North West
Washington, D.C. 20536, United States
-------Veterans Affairs Office of Inspector General (OIG) in Washington, D.C., United States for Tuesday, 1 August 2017 "VA Office of Inspector General Releases Inspection Report on Opioid Prescribing"
Veterans Affairs Office of Inspector General (OIG).
VA Office of Inspector General Releases Inspection Report on Opioid Prescribing
OIG’s inspection, Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care, identifies the need for improved care coordination between VA and non-VA healthcare providers prescribing opioids to veterans.
Veterans Affairs Office of Inspector General (OIG).
VA Office of Inspector General Releases Inspection Report on Opioid Prescribing
OIG’s inspection, Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care, identifies the need for improved care coordination between VA and non-VA healthcare providers prescribing opioids to veterans.
Veterans Affairs Office of Inspector General (OIG).
Veterans Affairs Office of Inspector General (OIG)
801 I Street North West
Washington, D.C. 20536, United States
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