OIG Monthly Highlights
Read about our top reports and investigations in October 2014 CONGRESSIONAL TESTIMONY Assistant Inspector General for Audits and Evaluations Testifies at House Committee on Veterans’ Affairs Subcommittee Field Hearing on the Operations of the Philadelphia, Pennsylvania, VA Regional Office Linda A. Halliday, Assistant Inspector General for Audits and Evaluations, testified at a field hearing of the Subcommittee on Disability Assistance and Memorial Affairs, Committee on Veterans’ Affairs, United States House of Representatives, on October 3, 2014. The hearing was held at the Pemberton, NJ, campus of Burlington County College and focused on the operations of the Philadelphia, PA, VA Regional Office (VARO). Ms. Halliday discussed the initial results of the Office of Inspector General’s (OIG) unannounced visit to the VARO in June 2014 and advised that OIG’s work continues on the issues raised during the visit. These issues include allegations that mail was not scanned timely into Virtual VA—the electronic claims repository; staff were hiding mail or shredding mail; staff were cherry-picking claims to process; and the VARO improperly implemented Fast Letter 13-10, which was rescinded based on the OIG’s June 2014 management advisory memorandum to the Under Secretary for Benefits. The OIG will issue a final report when our work is completed. Ms. Halliday was accompanied by Ms. Nora Stokes, Director, Bay Pines Benefits Inspection Division; Mr. Al Tate, Audit Manager, Atlanta Office of Audits and Evaluations; and Mr. Jeffrey Myers, Benefits Inspector, San Diego Benefits Inspection Division.
Review of Alleged Mismanagement at VHA’s Massachusetts Veterans Epidemiology Research and Information Center
In August 2013, the Senate Committee on Veterans’ Affairs asked the Office of Inspector General to review allegations that the Massachusetts Veterans Epidemiology Research and Information Center’s (MAVERIC) security control weaknesses put veterans’ personal information and other sensitive information at risk. It was also alleged that the Boston Healthcare System (BHS) leased off-site commercial office space for MAVERIC staff the complainant considered wasteful. We substantiated the allegation that MAVERIC security control weaknesses put veterans’ personal information and other sensitive information at unnecessary risk. In December 2013, we found hard copy veterans’ personal information and unencrypted portable data storage devices unsecured in MAVERIC office space. The Veterans Health Administration’s (VHA), Office of Research Oversight (ORO), found similar issues in August 2013 when it conducted a review of BHS’ research groups. In light of the issues identified during our review and by ORO, we concluded that BHS had not taken sufficient action to safeguard the confidentiality of veteran personal information. This occurred because BHS did not establish sufficient oversight of MAVERIC physical security controls, such as ensuring secure storage of veterans’ personal information and encryption of portable storage media. We also substantiated the allegation that BHS leased off-site commercial office space, which we determined was under-utilized. VA BHS entered into a 5-year lease totaling about $938,000 without determining how much office space it needed and whether there was available VA space. As a result, we estimate VA BHS could spend about $593,000 over the 5-year lease period for under-utilized office space. We recommended the Director of Veterans Integrated Service Network 1, in conjunction with the Office of Information and Technology, improve oversight of MAVERIC physical security controls and implement a plan to maximize use of the off-site commercial space if continued need for the office space is justified. The Director of the Veterans Integrated Service Network 1 concurred with our recommendations and provided acceptable action plans.
Healthcare Inspection – Evaluation of the Veterans Health Administration’s National Consult Delay Review and Associated Fact Sheet
OIG evaluated Veterans Health Administration’s (VHA’s) review of “unresolved” consults and the accuracy of VA’s summary, the National Consult Delay Review Fact Sheet (Fact Sheet), as requested by the Chairman of the House Veterans’ Affairs Committee (HVAC). Unresolved consults are requests for consultations that are open or active in patients’ electronic health records. In September 2012, VHA initiated a multi-phased review of consults that were unresolved for more than 90 days. By May 2014, the number of unresolved consults had decreased considerably. However, because VHA did not implement appropriate controls, we found it lacks reasonable assurance that facilities appropriately reviewed and resolved consults; closed consults only after ensuring veterans had received the requested services, when appropriate; and, where consult delays contributed to patient harm, notified patients as required by VHA policy. Our review of the Fact Sheet found several key statements related to the scope and results of VHA’s review of unresolved consults were misleading or incorrect. These statements were repeated by VHA leaders at meetings with congressional staff and during media events. In July 2014, VHA issued a letter to the Chairman of the HVAC that included information intended to clarify statements in the Fact Sheet. We recommended that the Interim Under Secretary for Health (1) conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA's system-wide consult review; (2) ensure that if a medical facility's processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care; and (3) after reviewing the circumstances of any inappropriate resolution of consults, confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.
Healthcare Inspection – Follow-Up Evaluation of Quality of Care, Management Controls, and Administrative Operations, William Jennings Bryan Dorn, VA Medical Center, Columbia, SC
At the request of Members of the House and Senate Committees on Veterans’ Affairs, the OIG conducted an evaluation of conditions identified in the OIG report Quality of Care, Management Controls, and Administrative Operations, OIG Report No. 13-00872-71, issued February 6, 2014 (the initial report), at the William Jennings Bryan Dorn VA Medical Center (facility), Columbia, SC. The purpose of this follow-up review was to determine whether identified conditions have abated, continued unchanged, or worsened and whether OIG’s recommendations were implemented. In the initial report, we noted that critical leadership positions were filled by a series of “acting” and temporary managers over a period of several years which contributed to past delays in correcting identified deficiencies. A permanent Chief of Staff and Medical Center Director were installed in January and April 2014 respectively, which has accelerated the facility’s progress in addressing deficient conditions. However, many of the problems outlined in our initial hotline report still existed, in whole or in part, at the time of our follow-up visit (July 2014). We found that the facility had implemented corrective actions in response to the 12 recommendations in our initial report, yet improvements were still needed. We agree with closure of 2 recommendations and will continue to follow up on the remaining 10 recommendations from the initial report. In addition, during the July 2014 visit, we found improper storage of patient information, medical and surgical supplies, medications, grafts, and patches. We made one additional recommendation related to proper storage.
Former Maryland Veterans Affairs Official Sentenced To Prison For Fraudulently Obtaining Over $1.4 Million In Benefits
Maryland Man Who Helped 17 People Submit False VA Claims Gets 1 Year+1 Day in Prison, Ordered to Pay Government Over $2.6 M
Tampa Man Pleads Guilty During Jury Selection In Stolen Identity Refund Case
Significant Prison Time Faces Florida Man Who Admits To Stealing Veterans’ Identities from James Haley VA Hospital
Audit of VHA's National Call Center for Homeless Veterans
Veterans Health Administration’s (VHA) National Call Center for Homeless Veterans (the Call Center) is VA’s primary vehicle for communicating the availability of VA homeless programs and services to veterans and community providers. OIG has assessed the effectiveness of the National Call Center for Homeless Veterans in helping veterans obtain needed homeless services. We determined that Homeless and at-risk veterans (Homeless Veterans) who contacted the Call Center often experienced problems either accessing a counselor and/or receiving a referral after completing the Call Center’s intake process. Of the estimated 79,500 Homeless Veterans who contacted the Call Center in fiscal year (FY) 2013: Just under 21,200 (27 percent) could only leave messages on an answering machine—counselors were unavailable to take calls; almost 13,000 (16 percent) could not be referred to VA medical facilities—their messages were inaudible or lacked contact information; and approximately 3,300 (4 percent) were not referred to VA medical facilities, despite having provided all the necessary information. Referred Homeless Veterans did not always receive the services needed because the Call Center did not follow up on referrals to medical facilities. Of the approximately 51,500 referrals made in FY 2013, the Call Center provided no feedback or improvements to ensure the quality of the homeless services. We noted that 85 percent of the 60 veterans’ records we reviewed lacked documentation to prove the veterans had received needed support services. Finally, the Call Center closed just under 24,200 (47 percent) referrals even though the VA medical facilities had not provided the Homeless Veterans any support services. In total, we identified 40,500 missed opportunities where the Call Center either did not refer the Homeless Veterans’ calls to medical facilities or it closed referrals without ensuring Homeless Veterans had received needed services from VA medical facilities. We recommended the Interim Under Secretary for Health stop the use of the answering machine, implement effective Call Center performance metrics to ensure Homeless Veterans receive needed services, and establish controls to ensure the proper use of Call Center special purpose funds. The Interim Under Secretary for Health concurred with our recommendations and provided responsive action plans. We will follow up on these actions.