VA Employee Charged With Falsifying Medical Records Of Numerous Veterans
Grand Jury Returns 50-Count Indictment Against VA Supervisor Who Falsified Consults at Charlie Norwood VA Medical Center in Augusta, GA. Indictment Based on Investigation by OIG Special Agents, Assisted by OIG Healthcare Inspections Clinical Staff.
Deputy Inspector General Announces Steps To Strengthen OIG Whistleblower Protection Ombudsman Program
I am initiating the following steps to further strengthen the Whistleblower Protection Ombudsman program in the VA Office of Inspector General (OIG). Improved Hotline submission process. The OIG Hotline is the front door for complainants to contact the OIG. In order to better serve complainants and review whistleblower concerns in an informed manner, we have created additional web forms designed to ensure anonymity, confidentiality, or allow for full identity disclosure...
Deputy Inspector General Announces Steps To Strengthen Whistleblower Protection Training for OIG Employees
One of my first acts as VA Deputy Inspector General is to take steps to ensure that all VA Office of Inspector General (OIG) employees are fully trained on protections and remedies guaranteed to Federal employees by the Whistleblower Protection Act, the Whistleblower Protection Enhancement Act, and related laws. To this end, I have decided to seek certification from the U.S. Office of Special Counsel under its 2302(c) Certification Program...
The VA Office of Inspector General (OIG) was not among the invited witnesses at the Senate Homeland Security and Governmental Affairs Committee hearing on June 3, 2015, “Watchdogs Needed: Top Government Investigators Left Unfilled for Years,” despite being the subject of undeserved, unfounded, and unsupported criticism. To set the record straight, we submitted a statement for inclusion in the hearing record trusting in the Committee’s respect for the principles of transparency and fairness. The Committee agreed to honor the OIG’s request and enter this statement into the hearing record.
Healthcare Inspection – Quality and Coordination of Care Concerns at Two Veterans Integrated Service Network 15 Facilities
OIG conducted an inspection to review allegations regarding the quality and coordination of care of a patient at the Kansas City VA Medical Center (VAMC), Kansas City, MO, and the Kirksville VA Clinic, a Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO clinic. We substantiated that the patient experienced multiple hip dislocations after replacement surgery. The recurrent hip dislocations resolved after revision surgery. We did not substantiate that the Kansas City VAMC delayed payment for ambulance transportation. We substantiated that the patient’s evaluation for potential aortic aneurysm repair was delayed, but did not substantiate that the aortic aneurysm probably resulted in his death or that VA providers inappropriately postponed surgical repair. We substantiated that the patient did not receive appropriate evaluation for recurrent falls and weakness; additionally, his primary care provider did not follow usual practice in prescribing medications associated with increased fall risk. We could not substantiate that the patient was involved in a motor vehicle accident at the VA. We found reports of a fall but no reports of a motor vehicle accident for the specified date. We substantiated that prescriptions were mailed to the patient after his death. We reviewed pharmacy data files to determine whether medications were being dispensed after patients’ deaths across Veterans Health Administration. We found that 17.2 percent of patients, or 29,173 patients, who died between July 1, 2013, to June 30, 2014, were dispensed at least one prescription after death on the average of 33 days after death; 96 percent of the dispensed medications were for non-controlled substances. We could not substantiate the allegation that the patient was denied care three times at the Kirksville CBOC. We made five recommendations. The Interim Under Secretary for Health, Veterans Integrated Service Network and Facility Directors concurred with our recommendations and provided acceptable action plans.
Healthcare Inspection – Care of an Urgent Care Clinic Patient, Tomah VA Medical Center, Tomah, Wisconsin
OIG conducted an inspection at the request of Senator Tammy Baldwin and Senator Ron Johnson to assess allegations of poor care and delayed care of a patient in the Tomah VA Medical Center (VAMC) Urgent Care Clinic (UCC) in Tomah, WI. We did not substantiate the general allegations of poor care and delayed care; that the patient waited 3 hours before being seen; that other patients arrived, were treated and released before the case patient; that a physician was unaware of acute ischemic stroke symptoms and treatment; or, that the Tomah VAMC computerized tomography machine was broken. We substantiated the allegation that the physician did not affirmatively diagnose the first neurologic event the patient experienced as a transient ischemic attack or acute ischemic stroke; however, the physician properly considered broad diagnostic possibilities for the syncopal episode, which occurred while the patient was in the Tomah VAMC UCC waiting room awaiting a mental health evaluation. We did not substantiate that the physician failed to treat the patient’s second neurologic event, an acute ischemic stroke, with sufficient urgency. We determined that transferring the patient to Gundersen Health System by ground ambulance was the appropriate action after a stroke was definitively diagnosed. We found that the Tomah VAMC does not own or operate an air ambulance and that one was not available to transfer the patient. We concluded that, overall, the UCC staff acted appropriately in the face of a patient experiencing a sudden and unexpected acute ischemic stroke while waiting for a mental health evaluation in a rural hospital that is not equipped to treat a health problem of this magnitude. We identified opportunities for improvement, none of which impacted this patient’s care, and made three recommendations to the Under Secretary for Health and six recommendations to the Tomah VAMC Director.
OIG Monthly Highlights
Read about our top reports and investigations in June 2015
Healthcare Inspection – Review of the Operations and Effectiveness of VHA Residential Substance Use Treatment Programs
In the Joint Explanatory Statement to accompany the fiscal year 2015 omnibus appropriations bill, Congress requested the OIG review the operations and effectiveness of VA substance abuse inpatient rehabilitation programs and report: (1) the current number of inpatient rehabilitation programs, (2) the annual number of veterans who participate and their average length of treatment, (3) the average length of time for VA treatment compared to non-VA residential treatment, (4) the rate of recidivism for both types of programs, (5) the process used to refer patients to VA treatment, (6) the degree of supervision of patients in VA programs and how often drug tests are performed, and (7) how well mental health and substance abuse treatment are integrated for veterans with comorbidities. We recommended Mental Health Services: Liaison with internal and external entities regarding standardized data collection from screening processes to core outcome measures to improve program monitoring and by which Mental Health Services can develop collaborative treatment initiatives; ensure system-wide use of the 596 stop code; review the consistency of current processes and provides specific guidance on reducing inflow of contraband into residential substance use treatment programs; consider requiring programs to document patients’ physical status in addition to presence when completing physical bed checks; clarify the intent of the requirement for and use of closed circuit television with respect to residential substance use programs; review and evaluate whether reversal agents such as naloxone are readily available at each residential substance use treatment program; encourage more widespread incorporation of programming with a specialized focus on mental health comorbidities; encourage discussion of addiction focused pharmacotherapy with residential substance use treatment program patients; ensure that active mental health comorbidities are addressed in residential substance use rehabilitation treatment program interdisciplinary treatment plans; and ensure documentation of post-discharge aftercare appointment arrangements for mental health comorbidities.
Statement of Linda A. Halliday Deputy Inspector General Office of Inspector General Department of Veterans Affairs Before the Subcommittee on Military Construction, Veterans Affairs, and Related Agencies Committee on Appropriations United States Senate Hearing on Whistleblower Claims at the U.S. Department of Veterans Affairs July 30, 2015
A Department Of Veterans Affairs Official And Durable Medical Equipment Vendor Charged With Health Care Fraud
Former Prosthetics Chief at W. Palm Beach, FL, VA Medical Center Accused of Conspiring With Vendor To Fraudulently Bill VA for Equipment Never Provided to Veterans.
Former VA Contractor Sentenced To Prison In Connection With Stolen Identity Refund Fraud
Judge Hands Down 6 Yrs+ Sentence for Tampa Man Who Stole Documents from James A. Haley VA Hospital