Federal Reports

The OIG reviewed the Veterans Health Administration’s (VHA’s) assessment and management of inpatient alcohol withdrawal following several OIG inspections where adverse clinical outcomes associated with alcohol withdrawal, likely contributing to patient deaths, were identified. Determining the severity of alcohol withdrawal is critical in facilitating treatment decisions that may prevent the progression of symptoms which could be fatal.Inpatient management of alcohol withdrawal is not specifically addressed in current VHA clinical guidance, and it does not fall under one VHA national program office. The OIG evaluated national and system-level written guidance for specificity to inpatient management of alcohol withdrawal in four key areas: determination of alcohol withdrawal severity, inpatient treatment of alcohol withdrawal, inpatient staff training for assessing alcohol withdrawal severity, and oversight for inpatient management of alcohol withdrawal (guidance and monitoring).The OIG found healthcare systems lacked written guidance related to assessing and reassessing alcohol withdrawal severity; determining the appropriate inpatient level of care; evaluating co-occurring conditions; consulting with substance use disorder experts; and pharmacotherapy. Written guidance was also lacking for when nurses should consult prescribers based on patients' alcohol withdrawal severity, when prescribers should evaluate patients face-to-face based on nursing assessment findings, and when to transfer care.Written guidance for inpatient management of alcohol withdrawal could decrease the risk of adverse patient safety outcomes and, along with training, facilitate knowledge of proper administration and consistency of assessments. Detailed expectations for oversight and monitoring would allow for quality of care to be evaluated and assessed for compliance with available substance use disorder guidance.The OIG made three recommendations to the Under Secretary for Health related to consideration of identifying a national office responsible for oversight, implementing written guidance for the management of alcohol withdrawal across inpatient settings, and implementing inpatient staff training on standardized alcohol withdrawal severity scales.

The VA Office of Inspector General (OIG) reviewed a former VA surgeon’s eligibility to provide health care as a participant in VA’s Community Care Network (CCN) and the Marion VA Health Care System’s (facility) management of community care patient safety events.The OIG identified multiple failures by third-party administrator (TPA), Optum, and VA Office of Integrated Veteran Care (IVC) that undermined credentialing and oversight processes, and ultimately allowed the subject surgeon to practice in the VA community care program. First, Optum failed to address concerns identified by a third-party certified verification organization in the surgeon’s 2018 credentialing file. Second, imprecise language in the VA’s contract with the TPA did not provide adequate guidance for Optum in determining whether to exclude the surgeon from the CCN. Additionally, IVC failed to identify inconsistencies in the surgeon’s credentialing file that should have impacted credentialing decisions. Finally, misapplication of privacy rules prevented Optum’s leaders from releasing important information to IVC relevant to the surgeon’s voluntary relinquishment of the Florida medical license. The OIG concluded that the facility’s patient safety training did not include completing patient safety event reports for events in the community and the patient safety manager was unaware of the ability to contact the TPA for updates on the status of patient safety concerns reported to the TPA.The OIG made two recommendations to the Under Secretary for Health related to review of the surgeon’s eligibility to participate in the CCN and CCN contract; four recommendations to the IVC Executive Director related to ensuring Optum’s sufficient review, documentation, and compliance of CCN providers; one recommendation to the VISN Director to review all community care provided by the surgeon; and one recommendation to the Facility Director related to patient safety event report education and follow-up.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the care provided at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued four recommendations for improvement in three areas:1. Medical staff privileging• Ongoing Professional Practice Evaluations o Equivalent specialized training and similar privileges o Service-specific criteria2. Environment of care• Safe and clean environment3. Mental health• Comprehensive Suicide Risk Evaluation completion

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report describes the results of a focused evaluation of the inpatient and outpatient care provided at the Miami VA Healthcare System, which includes the Bruce W. Carter VA Medical Center and multiple outpatient clinics in Florida.This evaluation focused on five key operational areas:• Leadership and organizational risks• Quality, safety, and value• Medical staff privileging• Environment of care• Mental health (suicide prevention initiatives)The OIG issued two recommendations for improvement in two areas:1. Quality, safety, and value• Peer reviews for unanticipated deaths within 24 hours of admission2. Medical staff privileging• Completion of Ongoing Professional Practice Evaluations for licensed independent practitioners