Federal Reports

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate allegations related to the care provided to a patient who died at the Charlie Norwood VA Medical Center (facility) and an allegation that the facility director failed to ensure adequate psychiatric provider coverage. The OIG did not substantiate that the patient died due to overmedication, because the cause of death was bilateral pulmonary thromboemboli with prolonged restraint and “noncontributory” toxicology findings. However, the OIG identified deficiencies during the patient’s care that likely contributed to the patient’s death. Staff improperly ordered and initiated medical-surgical restraint for the patient. Given that the patient was restrained for approximately 71 hours, the staff’s failure to effectively address the patient’s deep vein thrombosis prophylaxis needs contributed to the patient’s death. Staff’s failure to address the patient’s nicotine dependence may have contributed to the worsening of the patient’s agitation that led to restraint usage. Facility leaders and staff failed to comply with Georgia State law involuntary commitment process requirements. The OIG substantiated that the lack of mental health provider involvement likely contributed to the patient’s death, and the patient endured an unnecessary four-hour ambulance trip in restraints that likely contributed to the development of pulmonary thromboemboli.The OIG substantiated that the facility’s Downtown Division lacked adequate psychiatric providers to manage mental health emergencies and that leaders failed to ensure a psychiatrist was included on their code gray team. Also, nurse practitioners had been cancelling outpatient appointments so they could respond to Downtown Division mental health consult requests. The OIG concluded that the Disruptive Behavior Committee failed to provide input that may have reduced the patient’s risk of violence throughout the patient’s care and may have contributed to the mismanagement of the patient’s mental health treatment needs. The OIG made 18 recommendations.

VA spends millions of taxpayer dollars annually on healthcare resources procured without competition from affiliated educational institutions. This review focused on determining the extent of VA’s compliance with the requirement to obtain an Office of Inspector General (OIG) preaward review of healthcare resource proposals from affiliated institutions and the potential monetary impact for any noncompliance. Preaward reviews generally provide VA with pricing recommendations based on the affiliate’s actual expenses of providing the services and are used by VA contracting officers to negotiate fair and reasonable prices for the government and taxpayers. The OIG found VA awarded 227 contracts with a total value of $278.5 million without the required OIG preaward review for contracts above $500,000, which represents 63 percent of the contracts during the 5-year review period. A review of contract files and other sources revealed that contracting officers awarded contracts just below the review threshold and used a series or extended interim contracts to circumvent the review requirements. VA did not consider the monetary value of extending the contract periods when determining the value of the proposals and repeatedly used interim contracts to procure healthcare services without the required OIG preaward review. Additionally, contracting officers did not consistently document that the negotiated price was fair and reasonable, as required. The OIG recommended the Veterans Health Administration executive director for procurement ensure that contracting officers request preaward reviews for all sole-source healthcare resource contracts that exceed $500,000, require an OIG preaward review for all interim contracts that exceed the threshold, and mandate an immediate postaward review for any sole-source contract awarded on an interim basis as an emergency contract.

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