Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2020

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of VHA facilities’ selected requirements and guidelines for medication management. This evaluation focused on compliance with program requirements and processes related to long-term opioid use for pain.This report describes medication management findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and reviews of clinical and administrative processes. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews.The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with• aberrant behavior risk assessments,• concurrent benzodiazepine therapy,• urine drug testing,• informed consent,• patient follow-up, and• quality measure oversight.