Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the request of Chairman Mark Takano, and Representatives Julia Brownley, Chris Pappas, and Mike Levin, members of the House Committee on Veterans’ Affairs, to evaluate allegations related to a lack of care coordination for patients receiving ketamine for treatment-resistant depression (depression that has failed to respond after multiple treatments) in the community after authorizations for the care lapsed in September 2019 at the VA San Diego Healthcare System (facility) in California.The OIG substantiated that the facility ended authorizations for community care for patients receiving ketamine, a medication used for treatment-resistant depression, in October 2019 and again in March 2020. The discontinuation negatively affected 35 patients during the two time frames. While distress related to uncertainties about continuing ketamine treatment were identified as a contributory stressor, the OIG did not substantiate that discontinuation of community care resulted in a patient’s death by suicide as the community provider continued to offer ketamine treatment to that patient. The OIG also identified deficiencies in facility processes.The OIG concluded that risks for negative patient outcomes increased due to• communication and care coordination deficits,• terminating community care authorizations,• accelerating timelines for care transition,• uncertainties from changing treatment for complex patientsThe OIG made two recommendations to the Under Secretary for Health regarding community care providers’ review of VA’s protocol for ordering ketamine and research related to the use of ketamine for treatment-resistant depression. Four recommendations were made to the Facility Director related to community care processes for coordination of non-VA care and ensuring coordinated, clinically informed plans for transitioning remaining patients to care at the facility.

The VA Office of Inspector General (OIG) conducted an inspection at the Fayetteville VA Medical Center in North Carolina to determine the validity of allegations that facility staff failed to coordinate appropriate care for a patient seeking community living center (CLC) placement and respite care, and did not provide medications for the patient while at a community assisted living center.The OIG did not substantiate that the facility failed to coordinate placement for a patient seeking CLC care. The facility evaluated the submitted consults in a manner consistent with policy, and disapproved CLC placement when the patient’s functional status did not warrant placement. In the fall of 2020, the patient was approved for community nursing home placement.However, the facility failed to coordinate respite services for the patient. Community health staff did not properly determine the patient’s eligibility, and an interdisciplinary assessment was not completed to determine the patient’s eligibility as required.The OIG did not substantiate that the facility failed to provide medications for the patient while at a community assisted living center; however, when the patient needed to be seen by a community optometrist to obtain glaucoma medications, a community care optometry consult was not initiated.The OIG also identified that the psychiatrist used the involuntary commitment process in a manner that was inconsistent with the state’s established parameters, and failed to adequately assess and document the patient’s capacity to make informed decisions and determine whether the patient had a healthcare agent. In addition, the patient’s primary care providers and psychiatrist missed an opportunity to coordinate specialty care needs for the patient.The OIG made seven recommendations related to the evaluation, assessment of, and staff training for respite services; the psychiatrist’s use of involuntary commitment; patient decision-making capacity; identification of healthcare agents; and initiation of specialty care consults.

The Office of the Inspector General determined the Tennessee Valley Authority’s (TVA) industrial hygiene (IH) planning and assessment process had weaknesses that resulted in some hazards not being identified and evaluated. Specifically, we identified the following IH process weaknesses: (1) TVA relied on limited information to identify health hazards; (2) there was no formal evaluation of the risks posed by identified hazards; (3) IH plans did not prioritize hazards; and, (4) an incomplete monitoring process allowed for misalignment between plans and exposure assessments. We also determined TVA is taking appropriate actions to address adverse conditions which were identified during assessments at gas plants; however, hazard exposures were not documented and employees were not notified as required. In addition, we identified opportunities for improvement related to handling of IH issues in the contractor population.

The Office of the Inspector General included an audit of contractor use of TVA’s purchasing cards in its fiscal year 2021 Audit Plan, based on the significant amount of charges made using TVA purchasing cards assigned to contractors. The objective of the audit was to determine if adequate controls were in place to ensure purchases made by TVA contractors using a TVA purchasing card were (1) for TVA business purposes and not the use of another entity and (2) not being billed back to TVA. We found controls were generally adequate to ensure purchases made by TVA contractors using a TVA purchasing card were for TVA business purposes and not the use of another entity. However we also determined (1) TVA does not have controls in place to ensure purchases made by contractor employees assigned a TVA purchasing card are not being billed back to TVA on invoices from the contractor, (2) required language to govern contractor’s usage and liability for purchasing cards issued to TVA contractors is not included in contracts, and (3) over 50 percent of the transactions we tested were not reconciled by the cardholder in a timely manner, resulting in untimely approval by the approving official.