Healthcare Inspection – Opioid Agonist Treatment Program Concerns VA Maryland Health Care System, Baltimore, Maryland

OIG conducted a healthcare inspection in response to allegations made by a confidential complainant in 2015 regarding the Opioid Agonist Treatment Program (OATP) at the Baltimore VA Medical Center, one of three VA Maryland Health Care System campuses, located in Baltimore, MD. The complainant alleged the OATP lacked quality controls necessary to ensure patients received treatment planning and monthly counseling as required, which resulted in patient deaths. We substantiated that the OATP lacked effective quality controls necessary to ensure patients consistently received required treatment planning and monthly counseling. We determined the failure to provide consistent treatment planning and monthly counseling was due, in part, to a lack of counseling staff supervision. We did not substantiate that OATP patients died as a result. We also determined the OATP lacked a clear policy on cardiac risk management and quality controls to ensure appropriate cardiac monitoring. We identified a concern related to the role of the OATP Medical Director. 42 CFR § 8.12 (b) and the Substance Abuse and Mental Health Services Administration require that the medical director be responsible for ensuring regulatory compliance with all applicable Federal, State, and local laws and regulations. However, the OATP policy describing the medical director’s duties did not include regulatory compliance responsibility or define a sufficient number of hours to ensure regulatory compliance.