Federal Reports

The VA Office of Inspector General (OIG) conducted an inspection to review allegations that providers at the Charlie Norwood VA Medical Center in Augusta, Georgia, delayed care and failed to “provide services,” for a patient who died by suicide on the grounds of the Aiken Community Based Outpatient Clinic and the facility director “. . . covered it up.” The OIG also reviewed leaders’ responses to these allegations.The OIG substantiated the patient received deficient clinical care, which hindered referrals for mental health and pain management services. The deficiencies included (1) a primary care provider’s failure to follow up on positive mental health screenings, (2) a primary care provider’s failure to follow up on a discontinued mental health consult and order testing, (3) facility staff failures to ensure a timely pain management appointment, (4) pain management clinic providers’ failure to perform required mental health screenings, (5) a nurse’s failure to communicate a Veterans Crisis Line (VCL) referral prior to the Emergency Department encounter, and (6) suicide prevention staff failures to act after the VCL referral.The OIG did not substantiate that facility leaders “covered up” the patient’s death by suicide and could not determine the basis for this allegation due to the complainant being anonymous. Facility leaders immediately responded per Veterans Health Administration guidance; however, they failed to initiate a timely investigation of the death as a sentinel event.The OIG also identified completion of an inaccurate Behavioral Health Autopsy, failure to complete a Family Interview Tool Contact, delayed peer reviews, and a clinical review that did not identify and address deficiencies in care.The OIG made nine recommendations regarding mental health screenings, consult management, community care referral, suicide risk assessments, communication and closure of a VCL referral, completed suicides on VA campuses, and accurate completion of quality management reviews.

Peter Port, a resident of Palm Beach County, Florida, pleaded guilty on May 10, 2023, in the U.S. District Court, Southern District of Florida, to Conspiracy to Commit Health Care Fraud. Port owned and controlled Safe Haven, a substance abuse center, which was purportedly in the business of providing clinical treatment for persons suffering from alcohol and drug addiction.Our investigation found that Port and others paid kickbacks and bribes in the form of cash, free or reduced sober homes rent, and other benefits to individuals who agreed to be patients at Safe Haven. Fraudulent claims were subsequently submitted to insurance plans for unnecessary urine testing and addiction treatment services that were not provided. As a result of the scheme, Amtrak’s insurance providers were fraudulently charged approximately $86,130. Port and three co-defendants will be sentenced at a future date.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated about $17.2 billion in supplemental funds to the Veterans Health Administration (VHA) to support VA’s efforts to prevent, prepare for, and respond to the COVID-19 pandemic. The OIG conducted this audit to assess the effectiveness of VA’s controls over VHA’s use of these funds.Because VA’s financial management system does not support the direct obligation of supplemental funds for all expenses, staff used expenditure transfers to shift funds between appropriation accounts. Expenditure transfers are documented using journal vouchers, which are written documents explaining the purpose and details of the transaction. However, as VHA did not develop guidance for the type of documentation required, staff did not always sufficiently prepare the vouchers. As a result, staff could not always identify what was purchased or provide evidence the purchase was a proper use of CARES Act funds.Further, even when medical staff directly obligated from the CARES Act fund, they did not always (a) have documented purchase authority, (b) segregate duties, (c) properly track the receipt of goods to ensure the quantities ordered were received, or (d) properly certify and pay invoices. This occurred because VHA did not develop guidance with protocols for accounting processes and procedures or outline clear roles and expectations for the oversight of supplemental funds purchases. As a result, the OIG questioned an estimated $187.2 million.Until VHA strengthens controls over payments, it cannot be sure that payments have been properly made. Further, Congress lacks reasonable assurance that funds allocated for veterans’ COVID-19-related care are being spent as intended. The OIG recommended VA assess whether it can integrate its financial management system with other systems to reduce the need for expenditure transfers; the OIG also made eight recommendations to VHA to improve oversight of supplemental funds.