Federal Reports

The VA Office of Inspector General (OIG) conducted this review in response to a confidential hotline complaint alleging mismanagement of equipment and supplies that resulted in wasted funds and canceled operating room procedures at the Hampton VA Medical Center in Virginia. There were six allegations that included unused equipment left in an unmarked storage room and a warehouse. They also stated there was no inventory system to track operating room supplies and that the staff ordered too many supplies, spent excessively on overnight delivery charges, and that some operations were canceled because supplies were unavailable. According to the complaint, these deficiencies were addressed in earlier quality control reviews, but never addressed by facility leaders. The OIG did not substantiate that operating room procedures were canceled, nor that thousands of dollars were spent weekly to have supplies delivered overnight. However, about $1.8 million worth of equipment had sat for an undetermined amount of time in an unmarked second floor storage room and a warehouse basement without being properly inventoried. Facility staff were found to have ordered too many supplies, leading to overstocking and waste. The OIG partially substantiated the allegation that the facility did not have an effective, reliable inventory system in place to track or order operating room supplies. There were deficiencies, such as cluttered and overstocked operating room storage areas and inventory missing proper barcode labels, that had not been effectively addressed since they were identified in May 2017 and May 2018 quality control reviews. The OIG made several recommendations to the facility director for improving inventory management, including having a plan to ensure adequate staffing and implementing a process to address and correct deficiencies identified during quality control reviews in a timely manner.

This Comprehensive Healthcare Inspection Program (CHIP) provides a focused evaluation of the quality of care delivered at the Sheridan VA Medical Center, covering leadership, organizational risks, and key processes associated with promoting quality care. Focused areas 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 leaders were stable and actively engaged with employees and patients; and, upon review of the facility’s accreditation organization findings, sentinel events, disclosures, and patient safety indicators, the OIG did not identify any substantial organizational risk factors. However, the facility had a repeat finding with ongoing professional practice evaluations. The senior leaders were knowledgeable about selected SAIL and CLC metrics but should continue to take actions to sustain and improve performance of measures contributing to the SAIL “4-star” and CLC “1-star” quality ratings. The OIG issued 22 recommendations for improvement in the following areas: (1) Medical Staff Privileging • Focused and ongoing professional practice evaluation processes (2) Environment of Care • Infection control and general cleanliness • Mental health unit panic alarm testing response times • Mental health unit seclusion room flooring • Emergency generator testing (3) Controlled Substances Inspections • Reconciliation of dispensing and return of stock • Controlled substances order verifications • Routine inspections by controlled substances coordinators (4) Military Sexual Trauma (MST) Follow-up and Staff Training • Providers’ training (5) Antidepressant Use among the Elderly • Patient/caregiver education on medications (6) Abnormal Cervical Pathology Results Notification and Follow-up • Women Veterans Health Committee membership (7) Emergency Departments and Urgent Care Centers • Waiver for 24-hour operations • Staffing and call schedules • Use of required tracking program • Directional signage • Equipment/supply availability

The VA Office of Inspector General (OIG) conducted an inspection to review an allegation of poor quality of cancer care to a community living center (CLC) patient, and to follow up on the adequacy and implementation status of action plan items to address deficiencies identified by Veteran Integrated Network (VISN) 8 reviewers related to the care of 55 patients at the VA Caribbean Healthcare System (facility) in San Juan, Puerto Rico. The OIG substantiated that staff inadequately monitored the CLC patient. Documentation was insufficient and there were no care coordination agreements between the CLC and other services. Licensed practical nurses did not add registered nurses as co-signers to notes to alert them of changes in the patient’s status, and the patient’s care plan had not been modified to include the initiation of chemotherapy. The OIG found that action plan items did not comprehensively address all findings identified by non-facility VISN reviewers. While not an allegation, the OIG found that VISN 8 had contracted with a non-Veterans Health Administration reviewer to independently review eight patient cases for interrater reliability; however, the information provided to the interrater reviewer was not identical to the information provided to the non-facility VISN reviewers. The OIG made one recommendation to the VISN Director related to clear and consistent instructions for concurrent management reviews and six recommendations to the Facility Director related to the monitoring of chemotherapy patients, care coordination agreements between the CLC and specialty services, utilization of procedures regarding the communication of patient status changes, completion and accuracy of patient care plans, primary care provider training on prostate cancer patient management, and addressing the findings of the non-facility VISN reviewers.