Deficiencies in Facility Leaders’ Oversight and Response to Allegations of a Provider’s Sexual Assaults and Performance of Acupuncture at the Beckley VA Medical Center in West Virginia

The VA Office of Inspector General (OIG) conducted an inspection to examine oversight of a provider who engaged in sexual misconduct toward patients and practiced acupuncture without credentials or privileges. The OIG also reviewed leaders’ awareness and response to these issues. Current and former facility leaders gave conflicting information about their responsibility for the provider’s supervision and failed to complete the provider’s professional practice evaluations. Former facility leaders did not act upon awareness of patient complaints about the provider’s sexual misconduct. A facility leader removed the provider from patient care after learning of similar complaints at the provider’s previous employer but did not summarily suspend the provider. Following the provider’s termination, former facility leaders did not timely report the provider to state licensing boards. The provider also performed sensitive exams without a chaperone and former facility leaders did not address the provider’s refusal to use chaperones. The Veterans Integrated Service Network Director (VISN) initiated an Administrative Investigation Board (AIB) to determine if facility leaders addressed patient complaints. However, not all complaints were reviewed. Following awareness that the provider performed acupuncture without credentials and privileges, former facility leaders failed to ensure quality management reviews. The OIG identified the provider performed acupuncture on at least five patients and was unable to determine how needles were accessed, raising concerns about bloodborne pathogen exposure. Reviews were not conducted to identify if the provider performed acupuncture on patients. The VISN commenced a review identifying 48 patients. As a result, the VISN initiated testing patients for bloodborne diseases and facilitated the institutional disclosure process. The OIG made one recommendation to the VISN Director to ensure closure of AIB actions. The OIG made four recommendations to the Facility Director related to oversight, quality management actions, training, and reporting providers to state licensing boards.