Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System
- Read this Report
- Questions and Answers on the most significant aspects of the OIG’s report.
- Acting Inspector General's Oral Statement and Written Statement delivered before the House Committee On Veterans’ Affairs, September 17, 2014.
- Acting Inspector General's response to media coverage of baseless allegations on independence and integrity of the report.
OIG Monthly Highlights
Read about our top reports and investigations in August 2014 - OIG REPORTS Inspector General Issues Final Report on Phoenix Health Care System Waiting List, Makes 24 Recommendations to VA Secretary for Corrective Action This is the final report addressing allegations of gross mismanagement of VA resources, criminal misconduct by senior leadership, systemic patient safety issues, and possible wrongful deaths at the Phoenix VA Health Care System (HCS). The Office of Inspector General (OIG) found patients at the Phoenix VA HCS experienced access barriers that adversely affected the quality of primary and specialty care provided for them. Patients frequently encountered obstacles when patients or their providers attempted to establish care, when they needed outpatient appointments after hospitalizations or emergency department visits, and when seeking care while traveling or temporarily living in Phoenix.
Review of the Veterans Health Administration's Use of Reverse Auction Acquisitions
The VA Office of Inspector General (OIG) conducted a review of the Veterans Health Administration’s (VHA) use of commercial reverse auctions to procure products and services. The review determined that the methodology used to calculate and report savings by using reverse auctions greatly overstated any actual savings and did not comply with VHA’s Standard Operating Procedure (SOP). VHA’s mandatory requirement to use reverse auctions violated VA’s policy for using priority sources such as FSS contracts. Over 93 percent of the contract files reviewed did not contain proper documentation to validate the use of reverse auctions in accordance with VHA’s SOP. The review also determined that contracting officials run the risk of purchasing gray market items by using reverse auctions.
Administrative Investigation, Conduct Prejudicial to the Government and Interference of a VA Official for the Financial Benefit of a Contractor, Veterans Health Administration, Procurement & Logistics Office, Washington, DC
The VHA Deputy Chief Procurement Officer engaged in conduct prejudicial to the Government, a conflict of interest, improperly disclosed non-public VA information, misused her position and VA resources, engaged in a prohibited personnel practice, interfered with a VA OIG contract review, acted as an agent of FedBid Inc. in matters before the Government, and did not testify freely and honestly. Additionally, she, a close personal friend, and FedBid Inc. Executives, to financially benefit FedBid Inc., willfully and improperly acted to thwart a VA Official in his oversight duties associated with VA's procurement operations. Together they took significant measures to disrupt and deprive VA's right to transact official business honestly and impartially, free from improper and undue influence.
Community Based Outpatient Clinic Summary Report — Evaluation of CBOC Cervical Cancer Screening and Results Reporting
The purpose of our systematic review of the Veterans Health Administration’s (VHA’s) Community Based Outpatient Clinics (CBOCs) was to evaluate for compliance with selected VHA requirements regarding cervical cancer screenings and results reporting. Our review focused on two components (1) whether women veterans, ages 23–64, received cervical cancer screening and (2) whether ordering providers and patients received notification of cervical cancer screening results within the timeframes established by VHA policy (timeliness). The Office of Inspector General recommended that consistent processes be established for notifying (1) ordering providers of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record and (2) women veterans of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
Review of Alleged Data Manipulation at the Los Angeles VA Regional Office
On June 24, 2014, the Office of Inspector General received an anonymous allegation that Los Angeles VA Regional Office (VARO) management instructed staff to manipulate data to meet a Veterans Benefits Administration (VBA) claims processing timeliness goal. The complainant alleged that management told staff to update VBA’s electronic system to make it appear that VARO staff properly requested documentation to support veterans’ claims, although no actions were actually taken to obtain the required evidence. We did not substantiate the allegation that management instructed staff to input incorrect data in VBA’s electronic system. We determined VARO management provided written instructions to the assigned VSRs on initiating development of evidence to process 183 claims. However, we found that one of the seven VSRs assigned this workload had made entries in VBA’s electronic system to reflect documentation had been requested to support veterans’ claims, although the employee took no actions to obtain the required evidence. This VSR acknowledged manipulating data for claims, stating this was done to comply with verbal instructions from management. Based on our review, we concluded one employee misunderstood management’s instructions and made improper entries in VBA’s electronic system. Since the errors were the result of one individual, we did not consider this a systemic issue. However, given the nature and seriousness of the employee’s claims processing errors, we recommended that the VARO Director take action to correct the fourteen errors the employee introduced in the electronic records on the claims processed. We also recommended the Director ensure monitoring of all employees’ work to ensure that all future work is performed in accordance with VBA policy.
Former Federal Employee who Stole Government Property for Home Improvement Project
Supervisor at West Haven, CT, VAMC Who Had Employees Repair and VA Pay for Improvements to Her Residence Gets 6 Months Home Confinement, Community Service, and $15K Fine