Federal Reports

Our report contains 13 recommendations directed to the post and headquarters. We recommend that the post improve controls related to Volunteer health information, billing and collection, and imprest fund. Additionally, we recommend that headquarters revise policies and procedures related to the distribution of medical supplies to Volunteers, as well as administration of financial-system user roles.

The VA Office of Inspector General (OIG) initiated an inspection in response to anesthesia provider practice concerns, including unsafe practices such as technique and choice of medications, alleged to have affected patient care at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina. The OIG did not substantiate unsafe practices within the context of nine patient electronic health records reviewed. The OIG did not identify issues related to the quality of anesthesia care. However, initial hiring process deficiencies were noted related to the provider’s reporting, and the facility’s verification, of previous employment. The provider did not document a prior discharge from a position with a locum tenens contracting company, and facility credentialing and privileging staff did not complete timely verifications. The OIG also found gaps in the provider’s personnel file—proficiency reports for fiscal years 2013 and 2014 were missing, and when asked, facility staff were unable to locate them. The OIG noted that current Veterans Health Administration (VHA) policy does not specifically require physician applicants to list locum tenens contracting companies as part of their employment history, which could result in omissions and place facilities at risk for selecting unsuitable providers. The OIG determined that facility staff did not consistently follow VHA policy to report patient safety events and quality of care concerns, which affected facility leaders’ ability to respond and take action. The OIG made five recommendations including one to the Under Secretary for Health to review VHA’s credentialing policy related to applicants listing prior positions with contracting companies. The other four recommendations to the Facility Director related to ensuring timely applicant credentialing and privileging, completing and maintaining annual proficiency reports, providing performance and competency information to the Professional Standards Board for consideration during probationary and reprivileging reviews, and training facility staff on patient safety reporting.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate an allegation that a clinical pharmacy specialist (CPS) failed to act on a patient’s abnormal test results in fall 2018, which led to the patient going undiagnosed and untreated for pancreatic cancer for three months. The OIG determined that three months prior to the event, during an annual physical examination, a facility primary care provider failed to acknowledge or assess the patient’s unintentional weight loss. The OIG substantiated that the CPS failed to act on a patient’s abnormal test results and communicate those results to the patient. However, the OIG was unable to determine if immediate action by the CPS would have led to the patient receiving a prompt diagnosis and treatment for pancreatic cancer. The OIG found that the CPS also did not document a change in the patient’s plan of care. The current electronic health record used within the Veterans Health Administration (VHA) lacks a process to ensure that test results are communicated and acted upon by ordering providers. The OIG determined that facility policies and practices supported CPSs collaborating with primary care providers when a patient’s condition changed. Although the OIG found no evidence to indicate an overall lack of collaboration between providers and CPSs, in this case, the OIG determined that an opportunity for collaboration was missed. The OIG found that facility leaders provided oversight of patient care delivered by CPSs. The OIG made one recommendation to the Veterans Integrated Service Network Director to conduct a comprehensive review of the patient’s episode of care and take action as indicated. The OIG made one recommendation to the facility Director to ensure staff are aware of and follow the VHA directive regarding communication of test results.

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations of inadequate preoperative evaluations and the management of postoperative care for a patient approved for bariatric surgery at the VA Pittsburgh Healthcare System. The patient did not receive three required laboratory tests prior to bariatric surgery; however, the OIG did not substantiate that the patient was inappropriately approved for surgery. These omissions did not affect the clinical indication for surgery or the outcome. The OIG did not substantiate that the patient was inadequately evaluated by mental health providers prior to surgery. The Bariatric Surgery Program team considered the patient’s complex mental health history prior to approving the patient for surgery. The OIG substantiated that the Managing Overweight and/or Obesity for Veterans Everywhere coordinator overstated the patient’s mental health treatment and did not correct the documentation error after discovering it. Concerns were noted regarding the lack of a checklist and the use of informal communication instead of documenting interdisciplinary team discussions. The OIG concluded that an improved process could diminish the risk of an incomplete preoperative evaluation for future patients. The patient successfully underwent bariatric surgery in 2019. The OIG did not substantiate that the patient was insufficiently monitored following surgery. The patient received monitoring for medication, weight loss, and mental health symptoms. Approximately three months after surgery, the patient was seen in the Emergency Department and denied thoughts of self-harm in the previous two weeks. The patient completed suicide five days after the Emergency Department visit. The OIG made six recommendations to the Facility Director related to developing a facility policy for bariatric surgery; ensuring bariatric patients receive all preoperative medical and mental health evaluations; reviewing, correcting, and educating staff on documentation errors; documenting preoperative bariatric interdisciplinary team discussions; and reviewing the Bariatric Surgery Program.

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 Oscar G. Johnson VA medical center and multiple outpatient clinics in Michigan and Wisconsin. The inspection covers key clinical and administrative processes that are associated with promoting quality care. For this inspection, the areas of focus were Leadership and Organizational Risks; Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; 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. The medical center’s executive leadership team included four positions, one was permanently filled less than four months and one (chief of staff) had been vacant for three months prior to the OIG visit. Employee satisfaction survey results for the Director and the ADPCS were markedly higher than VHA averages. Leaders supported efforts to improve and maintain patient safety, quality care, and other positive outcomes. The leadership team was extremely knowledgeable within their scope of responsibility about Strategic Analytics for Improvement and Learning data and should continue to act to sustain and improve performance. No substantial organizational risk factors were identified. The OIG issued 11 recommendations for improvement: (1) Medical Staff Privileging • Professional practice evaluation processes (2) Medication Management • Aberrant behavior risk assessment • Urine drug testing • Informed consent • Follow up after therapy initiation • Pain Committee activities (3) Women’s Health • Women Veterans Program Manager collateral duties (4) High-Risk Processes • Sterile Processing Services annual risk analysis • Staff training

The objective for this report was to evaluate the extent to which the company employs key practices to ensure the efficiency and effectiveness of its police force. We found that, over the past two years, the company has significantly improved its oversight and management of its police department but has not reached a consensus on the full scope of Amtrak Police Department’s (APD) role and priorities—a foundational decision from which all other policing decisions flow. Further, the company has not developed systematic processes to determine APD’s optimum size or composition. As a result, the company does not have reasonable assurance that it is using its police department efficiently and effectively and could be exposed to unforeseen risks to its security, operations, finances, and brand.To better ensure that APD is effectively and efficiently meeting the company’s needs and addressing its risks, we recommended that the company and police department reach a consensus on the full scope of APD’s role and priorities. Once it has done so, we recommended that the company develop data‐driven, risk‐based processes to determine the department’s optimal size and staffing composition and ensure that those decisions—as well as decisions about allocation, goals, and metrics—align with APD’s role and priorities.