The VA Office of Inspector General (OIG) conducted a healthcare inspection to review an allegation that the Behavioral Health Service program manager denied 32 patients behavioral health community care services at the Oklahoma City VA Medical Center in Oklahoma (facility).During the review, the OIG substantiated that the program manager did not follow the consult management process and discontinued behavioral health community care consults for 29 patients. The OIG did not substantiate that the behavioral health patients were denied care but determined that the discontinued consults resulted in a delay of care for seven patients. The OIG determined that when the discontinued consults were identified, facility leaders initiated reviews and took timely action to ensure patients received the requested care.The OIG found that the program manager reviewed each community care consult and used an availability tool to identify open internal appointments, then incorrectly commented to schedule patients in specific internal openings and discontinued the consults. Despite completing required trainings, the program manager reported not recognizing that comments to schedule a patient into a specific opening could be considered a prohibited practice called blind scheduling, and incorrectly identified that the discontinue consult status allows further action to be taken. The OIG concluded that the program manager had poor knowledge of the consult management scheduling processes and failed to follow requirements for behavioral health community care consults that led to delayed care for seven patients. The Behavioral Health Service leaders and the patient safety manager reported concerns to facility leaders after identifying that the program manager was discontinuing consults. Facility leaders took actions, including investigating the reports and conducting quality reviews that showed no adverse events from the delays.The OIG made one recommendation to the Facility Director related to community care consult management and appointment scheduling processes.
| Report Date | Agency Reviewed / Investigated | Report Title | Type | Location | |
|---|---|---|---|---|---|
| Department of Veterans Affairs | Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma | Inspection / Evaluation |
|
View Report | |
| Commodity Futures Trading Commission | Removal Notice for CFTC OIG Inspection & Evaluation, CFTC Stress-Testing Development Efforts (February 1, 2024) | Other | Agency-Wide | View Report | |
| Department of Homeland Security | Semiannual Report to Congress | Other | Agency-Wide | View Report | |
| Department of Justice | Audit of the Office of Justice Programs Victim Assistance Funds Subawarded by the Georgia Criminal Justice Coordinating Council to the Southern Crescent Sexual Assault and Child Advocacy Center, Hampton, Georgia | Audit |
|
View Report | |
| Department of Justice | Review of the U.S. Department of Justice’s Accounting of Drug Control Funding Fiscal Year 2023 | Review | Agency-Wide | View Report | |
| U.S. Agency for International Development | Financial Audit of USAID Awards in Bangladesh Managed by the Social Marketing Company for the Period October 1, 2021, to September 30, 2022 | Other |
|
View Report | |
| U.S. Agency for International Development | Single Audit of Wildlife Conservation Society and Subsidiaries for the Year Ended June 30, 2019 | Other |
|
View Report | |
| Department of the Treasury | 15th SIGPR Quarterly Report to Congress | Semiannual Report | Agency-Wide | View Report | |
| U.S. Agency for International Development | Review of USAID's Reporting on Its Drug Control Program Budget and Accounting for Fiscal Year 2023 | Audit |
|
View Report | |
| Federal Deposit Insurance Corporation | DOJ Press Release: Philadelphia Man Indicted for Targeting U.S. Army Servicemembers in Conspiracy to Commit Identity Theft and Cyberstalking | Investigation |
|
View Report | |