Federal Reports

The VA Office of Inspector General (OIG) evaluated the quality of care delivered at the Michael E. DeBakey VA Medical Center. This included reviews of key clinical and administrative processes that affect patient care outcomes—Quality, Safety, and Value; Environment of Care; Medication Management; Coordination of Care; Diagnostic Care; Moderate Sedation; Community Nursing Home Oversight; and Management of Disruptive/Violent Behavior. OIG also provided crime awareness briefings to 171 employees.OIG identified certain system weaknesses in utilization management; environmental cleanliness; anticoagulation processes and staff competency; employee competencies for point-of-care testing; community nursing home committee representation, annual reviews, and cyclical monthly documentation; and establishment of an Employee Threat Assessment Team and employee training for management of disruptive/violent behavior.As a result of the findings, OIG could not gain reasonable assurance that: 1. Facility managers effectively monitor the documentation of physician advisors’ decisions in the required database. 2. Facility managers maintain clean floors and patient rolling equipment and ensure damaged patient rolling equipment is repaired.3. The facility reviews quality assurance data for the anticoagulation management program, clinicians obtain all required laboratory testing prior to initiating anticoagulants, and employees involved in the anticoagulant program complete competency assessments.4. The facility develops and implements employee competencies for glucometer point-of care testing and assesses competencies annually.5. Facility managers ensure required disciplines participate in Community Nursing Home Oversight Committee functions, monitor the community nursing home program, and assure the safe care of patients in those homes.6. The facility has an Employee Threat Assessment Team, and employees receive training to reduce and prevent disruptive behaviors.OIG made recommendations for improvement in the following six review areas: (1) Quality, Safety, and Value; (2) Environment of Care; (3) Medication Management; (4) Diagnostic Care; (5) Community Nursing Home Oversight; and (6) Management of Disruptive/Violent Behavior.

OIG conducted a healthcare inspection at the July 2014 request of Congressman Mac Thornberry to assess allegations at the Amarillo VA Health Care System (facility), Amarillo, TX, concerning provision of care at the Childress, TX, and Clovis, NM, community based outpatient clinics (CBOC); nursing supervision at the Childress, TX, CBOC; and scheduling issues at the Lubbock, TX, CBOC. We substantiated that from November 2012 through November 2014, the Clovis and Childress CBOCs had more than 100 patients who had not been seen for more than one year. However, we did not find a requirement that patients be seen yearly. We did not substantiate that in March 2016, the Childress CBOC had (1) inadequate space to provide care and ensure privacy, or (2) did not provide comprehensive care or the same level primary care that was provided at the facility. Services not available on-site were offered via other mechanisms. We substantiated that in January 2015, Registered Nurses (RN) and Licensed Vocational Nurses (LVN) performed clerical duties because the facility did not assign clerical staff to CBOCs. However, this was not a violation of Veterans Health Administration policy. We did not substantiate that in January 2015, nurses at the Childress CBOC lacked supervisory nursing oversight. Nursing staff were supervised and able to contact supervisors by phone and email. We substantiated that LVNs may have exceeded their scope of practice. After our 2015 visit, facility staff instituted a new process to provide patients access to an RN and/or a provider by phone when an RN or provider was not available on-site. We did not substantiate that in August 2014, Lubbock CBOC staff lacked training in scheduling patient appointments and/or destroyed documents and kept paper wait lists. We made two recommendations.

OIG conducted a healthcare inspection at the request of Senators Tammy Baldwin, Chuck Grassley, and Ron Johnson, and Representatives Ron Kind and Timothy Walz, to assess improper dental infection control practices and administrative action taken by the Veterans Health Administration (VHA) at the Tomah VA Medical Center, (facility) Tomah, WI. These practices potentially exposed 592 veterans to bloodborne pathogens (BBP), including human immunodeficiency virus and hepatitis B and C viruses. Facility leadership were unaware of the improper infection control practices until October 2016, when acting supervisor Dentist B reported to the Chief of Staff that Dentist A (hired in October 2015) used a non-VA unsterile bur during a dental procedure. Two factors that contributed to facility leaders not being aware of Dentist A’s improper infection control practices sooner were (1) failure of staff, despite safety and infection-control training, to report Dentist A’s breach of infection control practices, and (2) advance notification and other issues associated with Dental Clinic inspections. OIG determined that the facility, Veterans Integrated Service Network (VISN) 12, and VHA took appropriate follow-up actions and responded timely to patients’ potential exposure to BBP. The facility removed the non-VA unsterile bur from the operatory, reported the incident to Human Resources, briefed VISN 12 leadership, and directed Dentist A to leave the clinic. Dentist A subsequently submitted a letter of resignation. The Deputy Under Secretary for Health for Operations and Management convened a clinical episode response team (CERT) to identify steps to take in response to the potential exposure of patients to BBP which included identifying, testing, and treating patients. Facility leaders made timely large-scale disclosure to 592 patients and flagged patient Electronic Health Records as needed to alert primary care physicians to discuss follow-up. We made one recommendation to the VISN 12 Director and four recommendations to the Facility Director.