Federal Reports

CPF Audit Opinion and Financial Statements FY 2019 (October 31, 2019)

The VA Office of Inspector General (OIG) conducted this audit to determine if the Veterans Health Administration (VHA) is efficiently managing positive airway pressure devices (sleep apnea devices) and supplies for veterans diagnosed with sleep apnea. The number of veterans diagnosed with sleep apnea who receive devices and supplies increased dramatically between fiscal years 2014 and 2018. This has significantly increased the financial risk to VA. If VHA does not change its practices and leverage opportunities to save money, the OIG estimates it risks spending about $261.3 million over the next five years on devices and supplies veterans will not use. VHA did not efficiently manage sleep apnea devices and associated supplies. The OIG found that almost half of the 250,000 veterans issued a device from October 2016 through May 2018 used it less than half the time. This can reduce therapy effectiveness. The mismanagement occurred in part because VHA did not identify and follow up with veterans who were not using their devices as recommended. The OIG also found that VHA did not have a sleep medicine staffing model to help ensure it conducted patient follow up. A model will determine staffing to help ensure follow up is conducted. VHA could save up to $39.9 million per year by loaning devices to veterans rather than issuing them for permanent use. A loan program would allow unused devices to be returned and reused. VHA could save up to an additional $12.4 million per year by not purchasing device supplies for veterans who do not use their devices. The OIG made three recommendations to the under secretary for health regarding sleep apnea device management. The recommendations include studying staffing levels, looking at using existing technologies to better monitor device use, and looking at alternatives to purchasing devices.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Richard L. Roudebush VA Medical Center, covering leadership and organizational risks and key processes associated with promoting quality care. For this inspection, areas of focus included Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The leadership team was relatively new, having worked together for about four months as of the week of the OIG’s visit. Selected survey scores related to employee satisfaction and patient experience were generally better than the VHA average but revealed some opportunities for improvement. The OIG reviewed accreditation agency findings, sentinel events, adverse patient event disclosures, patient safety indicator data, and identified organizational risk factors. Leaders were generally knowledgeable about selected Strategic Analytics for Improvement and Learning metrics but should continue to act to sustain and improve performance of measures contributing to the facility’s “3-star” quality rating. The OIG issued 13 recommendations for improvement: (1) Quality, Safety, and Value • Peer Review Committee summary reports • Interdisciplinary review of utilization management data • Review of relevant literature in root cause analyses • Resuscitative episode reviews • Implementation and monitoring of corrective actions (2) Medical Staff Privileging • Focused professional practice evaluation processes (3) Environment of Care • Wheelchair maintenance (4) Medication Management: Controlled Substances Inspections • Controlled substances inspection report reviews • Signatures for controlled substances waste • Override report reviews (5) Geriatric Care: Antidepressant Use among Elderly • Patient/caregiver education • Medication reconciliation (6) Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership composition

During prior reviews, we determined that New York claimed Medicaid reimbursement for home and community-based services (HCBS) under Medicaid waiver programs that did not comply with Federal requirements. New York's Bridges to Health (B2H) was an HCBS waiver program.

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care delivered at Edith Nourse Rogers Memorial Veterans Hospital (the facility), covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The leaders had been working together for approximately 15 months. Selected employee satisfaction results indicated general satisfaction with facility leaders, but opportunities exist to improve workplace attitudes. Leaders were knowledgeable about selected Strategic Analytics for Improvement and Learning (SAIL) and community living center metrics but should continue to act to sustain and improve performance measures contributing to the SAIL “5-star” and community living center “2-star” quality ratings. The OIG issued 21 recommendations for improvement: (1) Quality, Safety, and Value • Interdisciplinary review of utilization management data • Root cause analysis processes (2) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (3) Environment of Care • Environmental safety and cleanliness • Medical supply storage • Panic alarm testing • Comprehensive emergency management plan (4) Mental Health: Military Sexual Trauma (MST) Follow-up and Staff Training • Military sexual trauma training (5) Geriatric Care: Antidepressant Use among the Elderly • Justification for medication initiation • Patient and/or caregiver education and evaluation of understanding • Medication reconciliation processes (6) Women Health: Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) High-Risk Processes: Emergency Department and Urgent Care Center Operations • 24-hour Urgent Care Center operations waiver • Appointed Urgent Care Center medical director • Urgent Care Center staffing • Urgent Care Center support services availability

This Comprehensive Healthcare Inspection Program provides a focused evaluation of the quality of care at the VA Central Western Massachusetts Healthcare System, covering leadership, organizational risks, and key processes associated with promoting quality care. For this inspection, the areas of focus were Quality, Safety, and Value; Medical Staff Privileging; Environment of Care; Medication Management: Controlled Substances Inspections; Mental Health: Military Sexual Trauma Follow-Up and Staff Training; Geriatric Care: Antidepressant Use among the Elderly; Women’s Health: Abnormal Cervical Pathology Results Notification and Follow-Up; and High-Risk Processes: Emergency Department and Urgent Care Center Operations. The facility’s executive leadership team appeared relatively stable, having worked together for 18 months at the time of the inspection. Employee and patient satisfaction scores were better than the VHA average, with some opportunity for improvement. The facility received preliminary denial, but later full accreditation from The Joint Commission. The facility’s accreditation findings, sentinel events, and disclosures identified areas for improvement. The leadership team was knowledgeable of Strategic Analytics for Improvement and Learning (SAIL) and community living center (CLC) metrics and should continue to act to sustain and improve performance of measures contributing to the SAIL “5-star” and CLC “3-star” quality ratings. The OIG issued 30 recommendations for improvement: (1) Quality, Safety, and Value • Peer review process • Utilization management process • Root cause analysis • Annual patient safety report (2) Medical Staff Privileging • Professional practice evaluations (3) Environment of Care • Environmental cleanliness and safety (4) Medication Management • Controlled substances inspectors’ appointments • Controlled substances inspections • Medication override process (5) Mental Health • Military Sexual Trauma training (6) Geriatric Care • Patient/caregiver education • Medication reconciliation (7) Women’s Health • Women Veterans Health Committee processes • Cervical cancer data tracking • Abnormal results notification (8) High-Risk Processes • 24-hour operations waiver • Staffing and call schedules • Services, equipment, and supply availability • Patient flow metrics • Directional signage • Psychiatric intervention room