Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Marion VA Medical Center in Illinois (facility) to review an allegation that a patient died due to complications from high cholesterol.The OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication.The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes.Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication, and failed to address a positive urine drug screen for cannabis.Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan.The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behaviorial health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments.The OIG made five recommendations related to ensuring behavioral health staff provide and document patient education regarding possible side effects of medications and adverse drug-drug interactions; timely communicating test results; monitoring implementation of Phase Four of the Psychotropic Drug Safety Initiative; ensuring primary care staff comply with entering return-to-clinic orders; and ensuring primary care and behavioral health staff document contacts, attempted contacts, and letters sent when a patient misses an appointment.

To see our report, click on the link below

To see the report, please click the link below

To see the report, please click the link below

Why OIG Did This Audit A previous OIG review found that medical equipment suppliers could bill Medicare for a noninvasive home ventilator (NHV) as if it were being used as a ventilator, when use of a lower cost respiratory assist device or basic continuous positive airway pressure device was indicated by the patient’s medical condition.Sleep Management, LLC (Sleep Management), was among the top three suppliers of NHVs in calendar years (CYs) 2016 and 2017. Medicare paid Sleep Management $36.8 million for NHVs during our audit period. Our objective was to determine whether Medicare claims submitted by Sleep Management for the monthly rental of NHVs complied with Medicare requirements.How OIG Did This AuditWe selected a random sample of 100 claim lines for the monthly rental of NHVs submitted by Sleep Management that Medicare paid in CYs 2016 and 2017 (audit period). An independent medical review contractor reviewed supporting documentation to determine whether the claim lines complied with Medicare coverage and payment requirements.

The investigation substantiated that a TVA employee negotiated employment with a contractor for whom he approved invoices; however, he did so with the knowledge and apparent support of TVA management. After becoming an employee of the contractor, he continued to approve invoices for the contractor (now his employer) as he had done while employed by TVA. While working for the Contractor, the subject potentially had direct access to the sensitive business information of vendors in direct competition with the employing contractor.The employee did not consult TVA Ethics for guidance on this matter while still employed by TVA.

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of the quality of care delivered in the inpatient and outpatient settings of the Cincinnati VA Medical Center and multiple outpatient clinics in Kentucky, Indiana, and Ohio. The inspection covers key clinical and administrative processes that are associated with promoting quality care. This inspection focused on Leadership and Organizational Risks; COVID-19 Pandemic Readiness and Response; Quality, Safety, and Value; Medical Staff Privileging; Medication Management: Long-Term Opioid Therapy for Pain; Mental Health: Suicide Prevention Program; Care Coordination: Life-Sustaining Treatment Decisions; Women’s Health: Comprehensive Care; and High-Risk Processes: Reusable Medical Equipment.Three of the medical center’s four executive leadership positions were occupied by acting staff. The Associate Director, the only permanently assigned leader, had been in the position for less than one year at the time of the OIG virtual review. Survey results revealed opportunities for the acting Chief of Staff to improve employee attitudes toward the workplace. Survey data also indicated that patients were generally satisfied with the care provided. However, gender-specific results highlighted opportunities to improve experiences in the inpatient and patient-centered medical home settings. The OIG identified concerns related to the identification of sentinel events and institutional disclosures. Leaders were knowledgeable about selected data used in Strategic Analytics for Improvement and Learning models and actions taken during the previous 12 months to maintain and improve performance.The OIG issued 16 recommendations for improvement in five areas:(1) Quality, Safety, and Value• Committee processes• Peer review processes• Root cause analyses(2) Medical Staff Privileging• Professional practice evaluations• Provider exit reviews(3) Mental Health• Suicide safety plans(4) Women’s Health• Designated women’s health providers• Women veterans health committee membership(5) High-Risk Processes• Standard operating procedures• CensiTrac® instrument tracking system• Eyewash station testing• Staff training