Healthcare Inspection – Quality of Care and Staff Safety Concerns at the Huntsville Community Based Outpatient Clinic, Huntsville, Alabama

OIG conducted an inspection to assess the merit of allegations concerning the quality of care provided by a primary care provider (PCP) and staff safety at the community based outpatient clinic (CBOC) located in Huntsville, AL. We substantiated the PCP did not consistently document opioid medication management, did not consistently document and respond to patients’ abnormal test results, and on one occasion, entered a derogatory comment in the electronic health record. We did not substantiate that the PCP had made multiple medication errors, failed to respond to health care concerns appropriately, failed to refer a homicidal/suicidal patient, forced patients to receive vaccinations, and treated patients preferentially causing them to request a transfer of care to another PCP. We did not substantiate that the PCP inappropriately instructed staff to shred patients’ non-VA medical documents; however, we found that staff did not consistently follow facility policy for the management of non-VA medical records. We did not substantiate that the PCP yelled and became upset when a CBOC staff cautioned the PCP to not perform a procedure that was not approved for the CBOC setting. However, we found that the PCP had performed other CBOC-setting approved procedures for which he/she was not privileged to perform. We did not substantiate that the facility did not respond to staff concerns about quality of care or safety. We substantiated that the CBOC did not initially have a mental health emergency standard operating procedure, and once developed, it did not include all actions staff might take when addressing a mental health emergency. We substantiated that the CBOC had non-functioning panic alarms. During our inspection, we noted that the facility did not have a pain management policy as required and did not complete mandatory electronic health record quarterly quality reviews for outpatient programs. We made nine recommendations.