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.
Deputy Inspector General’s Announcement
"Change is the law of life, and those who only look to the past or the present are certain to miss the future." President John F. Kennedy On June 29, 2015, the VA Deputy Inspector General, Richard J. Griffin, informed the VA Secretary Robert A. McDonald and the VA Office of Inspector General workforce of his intention to retire after 43 ½ years of Federal service. His last day as VA Deputy Inspector General will be Independence Day, July 4, 2015, a fitting day for an organization that prides itself on independence and integrity. Upon his departure, the VA OIG’s Assistant Inspector General for Audits and Evaluations, Linda A. Halliday, will assume the position of Deputy Inspector General. Mr. Griffin praised the VA OIG workforce, stating “Your collective effort and hard work have resulted in a remarkable record of performance and outstanding achievements. In the last 6 years alone, the VA OIG workforce has accounted for 1,931 reports; 11,350 arrests, indictments, convictions, and administrative sanctions; and achieved $22.5 billion in monetary impact, either through recommendations to VA in program efficiencies or in criminal fines, penalties, and sanctions representing a return on investment of $36 for every dollar invested in the OIG’s budget. In fact, in April 2015, the Brookings Center for Effective Management named the VA OIG the second most productive OIG organization in the Federal government based on the last 5 years’ return on investment.
OIG Releases White Paper on Evidence Supporting Administrative Closure of 2014 Tomah, WI, VA Medical Center Inspection on Opioid Prescription Practice
"Facts are stubborn things; and whatever may be our wishes, our inclinations, or the dictates of our passion, they cannot alter the state of facts and evidence." John Adams Since February 2015, the Office of Inspector General (OIG) has been working in good faith to provide the Senate Homeland Security and Governmental Affairs Committee with evidence supporting the OIG’s decision to administratively close the healthcare inspection into allegations of inappropriate opioid prescription practices at the Tomah, Wisconsin, VA Medical Center (VAMC), while balancing our obligation to protect sensitive information in veterans’ medical records, VA quality assurance documents, and the names of complainants and witnesses promised confidentiality by our inspectors. Nonetheless, on April 29, 2015, the Committee issued a subpoena seeking records that was significantly broader than the records initially requested in February 2015, and for some records that we previously provided to the Committee, including 140 healthcare administrative closures issued from 2006 to 2015...
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.
Review of Alleged Delays in Care Caused by Patient-Centered Community Care (PC3) Issues
OIG examined VHA’s use of Patient-Centered Community Care (PC3) contracted care to determine if it was causing patient care delays. We found that pervasive dissatisfaction with both PC3 contracts has caused all nine of the VA medical facilities we reviewed to stop using the PC3 program as intended. We projected PC3 contractors returned, or should have returned, almost 43,500 of 106,000 authorizations (41 percent) because of limited network providers and blind scheduling. PC3 contractors scheduled appointments without discussing the tentative appointment with the veteran, which VHA refers to as blind scheduling. We determined that delays in care occurred because of the limited availability of PC3 providers to deliver care. VHA also lacked controls to ensure VA medical facilities submit timely authorizations, and PC3 contractors schedule appointments and return authorizations in a timely manner. VHA needed to improve PC3 contractor compliance with timely notification of missed appointments, providing required medical documentation, and monitoring returned and completed authorizations. This was the second of a series of reports addressing PC3 service delivery issues. We are conducting additional reviews to evaluate the adequacy of the PC3 contract, provider networks, and the completeness of the medical documentation for PC3 payments. We will report these results separately. We recommended the Interim Under Secretary for Health ensure PC3 contractors submit timely authorizations, evaluate the PC3 contractors’ network, revise contract terms to eliminate blind scheduling, and implement controls to make sure PC3 contractors comply with contract requirements.
Combined Assessment Program Summary Report - Evaluation of Selected Requirements in Veterans Health Administration Community Living Centers
The purpose of the evaluation was to determine whether facilities complied with selected restorative nursing and dining requirements to assist community living center residents in maintaining their optimal level of functioning, independence, and dignity. The VA Office of Inspector General (OIG) conducted this review at 47 Veterans Health Administration medical facilities during Combined Assessment Program reviews performed across the country from October 1, 2013, through September 30, 2014. Although OIG noted high compliance in many areas, including provision of assistive eating devices to residents during meals, dining atmosphere, and honoring residents’ preferences, OIG identified opportunities for Veterans Health Administration facilities to improve and made seven recommendations.
Tax Fraudster Receives 27-Year Prison Sentence
Tampa Man Who Used Names Stolen from VA To File $3M in False Tax Returns Gets 27 Yrs in Prison, Ordered To Pay Restitution
Audit of VHA's Homeless Providers Grant and Per Diem Case Management Oversight
The VA Office of Inspector General conducted this audit to determine if the Veterans Health Administration’s (VHA) Grant and Per Diem (GPD) Program case management oversight ensures services to eligible veterans are provided in accordance with grant agreements. We found VHA’s oversight of homeless providers’ case management helped to ensure services were provided in accordance with grant agreements for those veterans in the Program. However, eligibility requirements need to be clarified so all homeless veterans have equal access to case management services. We found 15 of 130 VA medical facilities (12 percent) within 6 different Veterans Integrated Service Networks required veterans to be eligible for VA health care to participate in the GPD Program. GPD policy only requires an individual to have served in the active military, naval, or air service, and been discharged or released under conditions other than dishonorable. The VHA Handbook and US Code provide minimum active duty requirements to be eligible for VA health care benefits. VHA has been silent on addressing this additional eligibility requirement in its current policy. VHA has not aggressively pursued an Office of General Counsel formal opinion and confusion at all program levels regarding eligibility requirements has resulted in inequitable access to case management services. In addition, we observed medication security issues at 5 of 22 providers (23 percent) we visited within 5 of the 6 medical facilities in our sample. This occurred because VHA and program providers did not ensure controls were sufficient to properly secure medications. As a result, veterans’ health and rehabilitation are potentially at risk.
Healthcare Inspection – Evaluation of a Patient’s Care and Disclosure of Protected Information, Atlanta VA Medical Center, Decatur, Georgia
At the request of the Chairman and Ranking Member, Senate Committee on Veterans’ Affairs and the Chairman and Ranking Member, House Committee on Veterans’ Affairs, OIG conducted a review of a patient’s care at the Atlanta VA Medical Center (facility), Decatur, GA prior to the patient’s death and evaluated an improper disclosure of protected health information outside VA. We determined that facility staff provided, or attempted to provide, appropriate mental health (MH) treatment and psychosocial support services. Although the veteran verbalized suicidal ideation, she was reluctant to engage in psychotherapy. The veteran missed two MH appointments, but when contacted, exercised her right and declined further MH services. We identified appointment scheduling and follow-up deficiencies, a 23-day delay in placing a high-risk for suicide flag, and inconsistent compliance with some high-risk protocol requirements. However, we do not believe that these deficiencies had a direct impact on the outcome, as the veteran died more than 2 months after she was referred for placement on the high-risk protocol, more than a month after the missed MH appointments, and 1 week after a face-to-face contact with a clinician. We confirmed that information in the veteran’s electronic health record was improperly disclosed. The record was designated as “non-sensitive” at the time of the disclosure, and Veterans Health Administration currently lacks the ability to audit access to non-sensitive records. We recommended that the Interim Under Secretary for Health evaluate options to identify individuals who access non-sensitive patient EHRs. We also recommended that the facility Director ensure that staff comply with guidelines for appointment scheduling, notification, and follow-up; make patient contacts in accordance with treatment plans; and adhere to suicide prevention program requirements. The Interim Under Secretary for Health, and the Veterans Integrated Service Network and facility Directors, concurred with our recommendations and provided acceptable action plans.