The VA Office of Inspector General (OIG) conducted a follow-up healthcare inspection in response to a 2023 OIG report regarding mistreatment of a resident at the Miles City VA Community Living Center (CLC) and the Fort Harrison VA Medical Center (facility). The OIG did not receive new allegations but initiated the inspection to review the current state of the CLC, including corrective actions and sustainability of changes implemented by system leaders. In addition, the OIG reviewed staffing shortages affecting the quality of care for CLC residents.
The 2023 OIG report substantiated an allegation of resident mistreatment and identified issues related to reporting and oversight processes. The OIG made seven recommendations that were closed as of May 9, 2024. The OIG determined system leaders’ actions to address previously identified CLC deficiencies specific to rights of residents to refuse treatment, patient safety reporting, screening and admissions, physician care oversight and documentation, and nursing care operations were sustained; therefore, the OIG did not have recommendations related to these areas.
The OIG, however, identified gaps in CLC physician coverage and staffing shortages for the CLC physical therapist and social worker positions, affecting quality of care for residents. The OIG found that when the CLC physician was on extended leave, medical coverage was by phone to the facility medical officer of the day located over 300 miles away. Physical therapy needs, such as timely access to durable medical equipment, were still being covered by existing system staff. A social worker, to address residents’ psychosocial needs, had been hired as of September 11, 2024. While the OIG did not find that the CLC staffing shortages resulted in resident harm, the gaps and shortages may limit access to and continuity of care for residents. The OIG made two recommendations to the Facility Director regarding staffing.
Miles City, MT
United States
