Healthcare Inspection – Primary Care Provider’s Clinical Practice Deficiencies and Security Concerns, Fort Benning VA Clinic, Fort Benning, Georgia

OIG conducted a healthcare inspection regarding clinical practice concerns and lack of security at the Fort Benning, Georgia, VA Clinic (Clinic), located at the U.S. Army Garrison and part of the Central Alabama Veterans Health Care System (system). The complainant alleged that a Primary Care Provider (PCP X) did not follow up on elevated prostate-specific antigen (PSA) results, evaluate a patient’s condition, provide timely care, or respond to patient requests for specialty care/pharmacy services. The complainant also alleged the Clinic lacked VA Police presence and panic alarms. We substantiated that PCP X did not routinely follow up on elevated PSA results, which delayed a patient’s prostate cancer diagnosis and treatment. Also, system leaders did not consistently monitor PCP X’s performance or take adequate administrative action. We notified system and VISN 7 leaders about PCP X’s performance and compromised quality of care. Although we did not substantiate that PCP X failed to evaluate a patient’s condition, documentation was regularly inconsistent with presenting conditions, diagnoses, and treatment plans. PCP X did not consistently submit appropriate consultations, follow up on consultant recommendations, or include relevant information to support consultations as required by VHA policy. We substantiated that PCP X did not provide care for an unscheduled patient (another PCP provided care), failed to provide timely care for two patients, and did not respond to a specialty care request. We did not substantiate that PCP X failed to respond to pharmacy service requests. We substantiated the Clinic lacked VA Police presence, but U.S. Army Garrison police responded to calls. We substantiated the Clinic lacked panic alarms, which were not required. Clinic staff also did not receive emergency procedures training or information. We made eight recommendations.