Federal Reports

The VA Office of Inspector General (OIG) conducted a focused evaluation of the quality of care delivered at the New Mexico VA Health Care System (facility). The review covered key clinical and administrative processes associated with promoting quality care—Leadership and Organizational Risks; Quality, Safety, and Value; Medication Management: Anticoagulation Therapy; Coordination of Care: Inter-Facility Transfers; Environment of Care; High-Risk Processes: Moderate Sedation; and Long-Term Care: Community Nursing Home Oversight. OIG provided crime awareness briefings to 33 employees.The facility has generally stable executive leadership to support patient safety, quality care, and other positive outcomes. However, the presence of organization risk factors, as evidenced by sentinel events, disclosures, and Patient Safety Indicator data, may contribute to future issues of noncompliance and/or lapses in patient safety unless corrective processes are implemented and continuously monitored. Facility leaders should continue to take actions to improve performance of selected Strategic Analytics for Improvement and Learning metrics, particularly Quality of Care and Efficiency metrics.OIG noted findings in the six areas of clinical operations reviewed and issued 20 recommendations that are attributable to the Facility Director, Chief of Staff, Nurse Executive, Associate Director, and Assistant Director. The identified areas with deficiencies are:(1) Quality, Safety, and Value • Ongoing Professional Practice Evaluation data review• Utilization management documentation(2) Medication Management: Anticoagulation Therapy• Quality assurance data review• Patient education• Required laboratory tests • Employee competency assessments (3) Coordination of Care: Inter-Facility Transfers• Transfer data analysis and reporting • Patient transfer documentation • Communication with accepting facility (4) Environment of Care• Environment of care rounds frequency and attendance• General cleanliness• Outdated supplies• Physical security risk assessment • Mental health unit employee and inspection team training(5) High-Risk Processes: Moderate Sedation• Informed consent• Timeout participation and checklist(6) Long-Term Care: Community Nursing Home Oversight• Oversight committee representation • Monthly clinical visits

OIG conducted an inspection in response to allegations regarding gynecology and women’s health primary care services at the VA Gulf Coast Veterans Health Care System (system), Biloxi, MS. Specifically, the allegations were that a system gynecologist turned away patients by cancelling their consults for routine cancer screenings; did not order the correct test for a patient who was contemplating a hysterectomy; refused to perform two tubal ligations; refused to reorder medications for a patient; failed to document gynecology procedures correctly; and failed to use a colposcope to perform colposcopies. Additional allegations were that a Women’s Health Clinic physician assistant was not addressing a patient’s medical care and that system gynecologists lived too far away to be on-call for surgical patients. We did not substantiate the above allegations, except that a system gynecologist did not reorder a medication for another gynecologist’s patient. However, we determined that it was reasonable for the covering gynecologist to defer reordering to the regular gynecologist. During the inspection, we identified several issues under the responsibility of medical leadership: providers did not always follow Veterans Health Administration (VHA) cervical cancer screening guidelines; loop electrosurgical excision procedures were performed in the operating room with general anesthesia; communication and collaboration was lacking between gynecologists and providers and between providers and patients that may have affected safe and effective patient care; a care coordination agreement was outdated; and one gynecologist’s privileges were not in compliance with system required experience to perform surgical procedures. We also found that the Patient Advocacy Program, under the responsibility of system leadership, was not tracking complaints as required by VHA. We made six recommendations.

OIG conducted a healthcare inspection to assess the merit of allegations from a complainant about mental health care provided to a patient at a Veterans Integrated Service Network 16 facility, prior to his suicide. We substantiated that the patient had been reasonably stable on his medication regimen, including clonazepam, for many years and that the patient was not placed back on his preferred medication (clonazepam) by psychiatrists despite his requests to do so. We substantiated that the patient was not admitted to the psychosocial residential rehabilitation treatment program and identified several barriers to the patient’s admission including misconceptions about admission criteria, delays in tuberculosis testing, poor communication between providers, and delays in contacting the patient. We found that, contrary to Veterans Health Administration (VHA) policy, the patient’s treatment preferences were not considered, nor was the patient informed of his right to appeal treatment decisions made by mental health staff. Furthermore, refusal on the part of the patient’s psychiatrist to treat the patient unless he agreed to not taking clonazepam created a treatment impasse and violated VHA policy.We found that because of limited availability of psychiatry appointments, the patient did not have timely access to mental health care after his discharges from community psychiatric hospitals and as his mental health condition worsened, other care options, such as Non-VA care, were not explored. We found that communication and planning by the patient’s mental health providers was not commensurate with the patient’s needs. In spite of the patient’s deteriorating mental health condition, multiple suicide attempts, and frequent hospitalizations, his underlying bipolar disease was not adequately treated, and ultimately, his poorly controlled mood disorder was the likely underlying cause for the patient’s suicidal thinking. We made 12 recommendations.

Wisconsin Physicians Service Insurance Corporation understated its Medicare segment pension assets as of December 31, 2013, by $3.2 million.

Wisconsin Physicians Service Insurance Corporation understated its Medicare segment pension assets as of December 31, 2009, by $33,000.

Wisconsin Physicians Service Insurance Corporation, understated its Medicare segment pension assets as of December 31, 2012, by $242,000.

The State survey agency did not always verify the correction of nursing home deficiencies identified during surveys in 2015 in accordance with Federal requirements.