Federal Reports

OIG conducted a healthcare inspection at the request of Senators Tammy Baldwin, Chuck Grassley, and Ron Johnson, and Representatives Ron Kind and Timothy Walz, to assess improper dental infection control practices and administrative action taken by the Veterans Health Administration (VHA) at the Tomah VA Medical Center, (facility) Tomah, WI. These practices potentially exposed 592 veterans to bloodborne pathogens (BBP), including human immunodeficiency virus and hepatitis B and C viruses. Facility leadership were unaware of the improper infection control practices until October 2016, when acting supervisor Dentist B reported to the Chief of Staff that Dentist A (hired in October 2015) used a non-VA unsterile bur during a dental procedure. Two factors that contributed to facility leaders not being aware of Dentist A’s improper infection control practices sooner were (1) failure of staff, despite safety and infection-control training, to report Dentist A’s breach of infection control practices, and (2) advance notification and other issues associated with Dental Clinic inspections. OIG determined that the facility, Veterans Integrated Service Network (VISN) 12, and VHA took appropriate follow-up actions and responded timely to patients’ potential exposure to BBP. The facility removed the non-VA unsterile bur from the operatory, reported the incident to Human Resources, briefed VISN 12 leadership, and directed Dentist A to leave the clinic. Dentist A subsequently submitted a letter of resignation. The Deputy Under Secretary for Health for Operations and Management convened a clinical episode response team (CERT) to identify steps to take in response to the potential exposure of patients to BBP which included identifying, testing, and treating patients. Facility leaders made timely large-scale disclosure to 592 patients and flagged patient Electronic Health Records as needed to alert primary care physicians to discuss follow-up. We made one recommendation to the VISN 12 Director and four recommendations to the Facility Director.

Due to concerns identified in a prior review related to the length of time Transmission and Power Supply (TPS) direct charge materials had been stored at the Muscle Shoals Distribution Center (MSDC), we initiated an evaluation to determine if TPS direct charge materials were being managed appropriately. In summary, we determined TPS direct charge materials were not being managed appropriately because: (1) direct charge materials were not purchased in accordance with TVA policy, (2) TPS does not keep track of direct charge materials stored at MSDC, and (3) direct charge materials are being stored at MSDC even though the work orders for which they were purchased have closed. Inappropriately managing TPS direct charge materials could increase the risk of loss, theft, or the over purchase of materials. In addition, project costs could be overstated and funds spent on items that go unused.