Comprehensive Healthcare Inspection Program Review of the Roseburg VA Health Care System, Oregon

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the Roseburg VA Health Care System (Facility). The review covered key processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Credentialing and Privileging; Environment of Care; Medication Management: Controlled Substances (CS) Inspection Program; Mental Health Care: Posttraumatic Stress Disorder Care; Long-Term Care: Geriatric Evaluations; and Women’s Health: Mammography Results and Follow-Up. The Facility has been and continues to be in transition. Three of the four executive leaders were new to their positions, and two were in temporary assignments. Facility challenges including ineffective leadership, toxic culture, personnel practices, and improper admission practices have been reported by media and were the subject of recent internal and external evaluations. The OIG reviewed accreditation organization findings, sentinel events, disclosures, Patient Safety Indicator data, and Strategic Analytics for Improvement and Learning results and did not identify any substantial organizational risk factors. However, the OIG identified concerns with hydromorphone (pain medication) shortages, gaps in provider privileging processes, and inadequate tracking and monitoring of On-demand supplies. The senior leadership team appeared aware of the magnitude of the challenges and were taking action to restore a culture of trust, increase employee and patient satisfaction, and improve the quality of care and efficiency metrics contributing to the “1-Star” rating. The OIG noted findings in three of the seven areas of clinical operations reviewed and issued seven recommendations that are attributable to the Interim Director, Acting Chief of Staff, and Associate Director. The identified areas with deficiencies are: (1) Credentialing and Privileging • Focused and Ongoing Professional Practice Evaluations processes (2) Environment of Care • Storage of cleaning solutions in food preparation areas (3) Medication Management: CS Inspection Program • CS monthly inspections • CS reconciliation