Federal Reports

The VA Office of Inspector General (OIG) reviewed concerns related to the care of a patient who died by accidental overdose approximately seven weeks after a missed appointment at the VA Central Ohio Healthcare System in Columbus (facility). The OIG evaluated staff’s failure to conduct minimum scheduling efforts due to an error in new electronic health record (EHR) functioning. The OIG reviewed the adequacy of mental health evaluations of the patient, supervision of a psychologist, caring communications management, and an internal review of the patient’s care.The OIG found that due to the EHR system error, the patient’s missed appointment was not routed to a queue to prompt rescheduling efforts. The OIG determined that, unlike established care standards, for sites using the new EHR, VHA required fewer patient contact attempts following missed mental health appointments. The OIG found that the nurse practitioner did not evaluate a request from the patient to restart medication nor obtain a comprehensive mental health history. The psychologist did not thoroughly evaluate or address the patient’s depression and failed to reconcile critical clinical information. The OIG would have expected a supervisory psychologist to identify concerns about the patient’s depression, substance use relapse risk, and suicidal behavior, and ensure follow-up regarding the medication request. The OIG found that staff failed to send the patient caring communications after high risk for suicide patient record flag inactivation. Facility leaders did not communicate a root cause analysis Lesson Learned to staff as expected.The OIG made one recommendation to the Deputy Secretary to monitor new EHR scheduling functionality. The OIG made two recommendations to the Under Secretary for Health to evaluate minimum scheduling effort requirements and establish Lessons Learned guidance. The OIG made two recommendations to the Facility Director to review the patient’s care and Caring Communication Program compliance.

In November 2021, Congress passed the VA Transparency & Trust Act of 2021 (Transparency Act) to provide oversight of VA’s spending of COVID-19–related emergency relief funding, including funding related to the Families First Coronavirus Response Act (FFCRA), Coronavirus Aid, Relief, and Economic Security (CARES) Act, and American Rescue Plan (ARP) Act of 2021. To comply, VA must provide a detailed plan to Congress outlining its intent and justification for obligating and expending funds covered by the act. Additionally, the Transparency Act requires VA to submit biweekly reports to Congress detailing its obligations, expenditures, and planned uses, as well as justification for any deviation from the plan. The act also requires the VA OIG to submit semiannual reports comparing how VA is obligating and expending covered funds to the planned obligations and expenditures. In this fifth report, the OIG found that VA’s last biweekly report was dated June 6, 2023; VA stated it received approval from Congress to deviate from the biweekly reporting requirement but has not been able to provide documentation to support this statement. VA’s reported obligations through the fourth quarter of fiscal year 2023 generally aligned with the ARP Act spend plan obligation schedule with few exceptions. Deviations to the spend plan did not affect VA’s compliance with the Transparency Act. However, the OIG found that VA’s lack of reporting does not provide sufficient documentation and precludes Congress and other external parties from determining if funds were properly obligated and expended as required.