http://www.va.gov/oig/rss/reports-rss.asp Official reports of the VA Office of Inspector General en-us Copyright 2008 VA Office of Inspector General http://www.va.gov/oig/rss 10/7/2008 12:20:08 PM VAOIGWebmasters@va.gov http://www.va.gov/oig/54/reports/VAOIG-08-01362-03.pdf The purpose of the inspection was to determine the validity of an anonymous allegation that “a number of patients” died while under the care of a board certified surgeon. We concluded that that the system took appropriate actions to ensure patient safety and to review the provider’s quality of care prior to and during Office of Inspector General’s review of the allegations. We also recommended that Regional Counsel review all pertinent documentation and actions taken by the system and determine whether the system had a legal obligation to report the provider to the NPDB and/or the appropriate state licensing boards.\n\r 10/6/2008 http://www.va.gov/oig/52/reports/2009/VAOIG-08-02110-02.pdf 10/6/2008 http://www.va.gov/oig/52/reports/2008/VAOIG-08-00244-213.pdf The Veterans Health Administration lacks effective controls over the use of prior-year funds. The audit identified unapproved and improper use of expired funds in at least 80 percent of Veterans Integrated Service Network contracting activities nationwide amounting to a total of $16.4 million during fiscal year 2007. This widespread improper use of expired funds occurred primarily because of a lack of policy clarity and other weaknesses in internal controls, such as inadequate monitoring of obligations and verification of obligation documents. This project followed-up on the May 2007 audit that substantiated similar misuse at the VA Boston Healthcare System, as discussed in a Congressional oversight hearing in June 2007.\n\r\n\rThe audit report made seven recommendations to improve controls on expired funds. The Under Secretary for Health concurred with the audit recommendations and monetary benefits. He agreed to increase central control on obligations using expired funds and to provide revised guidance and training on the use of such funds and to develop procedures to verify obligation documents and adjustments to correct the funding issues we identified. He also agreed to develop controls over other activities using expired funds and to take action against contracting officers who misused expired funds. VHA’s target date for completing the last planned action is April 30, 2009.\n\r 9/30/2008 http://www.va.gov/oig/52/reports/2008/VAOIG-08-00477-211.pdf The Veterans Health Administration (VHA) lacks reasonable assurance it received the services it paid for because performance monitoring controls over noncompetitive clinical sharing agreements are not effective. Strengthening controls over performance monitoring of noncompetitive clinical sharing agreements could save VHA about $9.5 million annually or $47.4 million over 5 years. Of the estimated savings, only about $96,000 in charges resulting from calculation errors may be recoverable because the terms of most of the sharing agreements we reviewed did not include provisions for adjusting payments. We found performance monitoring weaknesses for all 58 surgical and anesthesiology sharing agreements we reviewed at 8 VA medical facilities. As a result, for 30 (52 percent) of the 58 agreements, the medical facilities overpaid contractors because contracting officers’ technical representatives (COTRs) did not verify that medical facilities received the services required at the prices specified. \n\rIn addition to performance monitoring issues, we also found that during negotiations of per-procedure sharing agreements, Veterans Integrated Service Network (VISN) contracting officers agreed to pay at least full Medicare rates. However, the full Medicare rates include a practice component for overhead charges that contractors do not incur when they provide services at VA medical facilities. Excluding the Medicare practice component, as required by VA policy, could have saved VHA about $2.5 million annually or $12.4 million over 5 years.\n\rThe audit report makes five recommendations to improve clinical sharing agreement monitoring and two recommendations to ensure that onsite clinical service sharing agreement rates are not based on the Medicare practice component.\n\r 9/29/2008 http://www.va.gov/oig/54/reports/VAOIG-06-02459-209.pdf The Office of Inspector General evaluated the extent to which Veterans Health Administration (VHA) implements measures proven to prevent venous thromboembolism (VTE) in hospitalized patients. VTE includes deep vein thrombosis (DVT), a blood clot in the deep veins of the leg or pelvis, and pulmonary embolism (PE), a blood clot propagated to the lungs. We found that 63 percent of at-risk patients received recommended interventions, a rate similar to that at non-VA hospitals. Among patients who had PE while hospitalized, 17 percent received no preventive care before the event. Rates of appropriate care were similar at teaching and non-teaching hospitals. We recommended that VHA develop and implement a plan to ensure that hospitalized patients at risk for VTE receive accepted preventive therapies, and monitor rates of preventable VTE outcomes. 9/26/2008 http://www.va.gov/oig/52/reports/2008/VAOIG-08-00456-207.pdf The Office of Inspector General conducted an audit of FY 2007 VA purchases made on behalf of the Department of Defense (DoD). The purpose of the audit was to evaluate the effectiveness of internal controls over purchases made by VA contracting activities on behalf of DoD. VA contracting activities generally increased their compliance rates with Defense procurement requirements when making purchases on behalf of DoD since our audit of FY 2006 procurements. Although we found increased rates of compliance, we again identified instances of noncompliance in FY 2007 procurement actions, which increased the risk that DoD did not receive contracted goods and services on terms that were the most advantageous to the Government. VA contracting officers did not always: (i) ensure that noncompetitive acquisitions were adequately justified; (ii) obtain offers from at least three contractors or prepare written justifications explaining why they did not meet the competition requirements when making purchases costing more than $100,000 from Federal Supply Schedule (FSS) contractors; (iii) seek price reductions for orders exceeding the maximum order threshold when ordering goods or services from FSS contractors; (iv) ensure that price reasonableness determinations were adequately documented in contract files; (v) ensure that contracts for services included quality assurance surveillance plans; (vi) designate contracting officer representatives in writing before contract performance began, and (vii) stay within their warrant authority limitations when purchasing goods and services for DoD. 9/24/2008 9/23/2008 http://www.va.gov/oig/CAP/VAOIG-08-00916-204.pdf The purpose of this review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we also provided fraud and integrity awareness briefings to 180 employees. This review focused on five operational areas. The medical center complied with selected standards in the following two areas (1) emergency department and (2) patient satisfaction. We identified information security and privacy and respiratory hygiene as organizational strengths. We made recommendations for improvements in the following three areas: Environment of Care – Ensure that duress alarms on the locked mental health unit are properly located and functioning and that construction barriers are intact. QM – Review physician privileges to ensure currency of competencies, ensure that all appropriate clinical staff maintain current cardiopulmonary resuscitation certification, improve timeliness of peer review referrals, and improve compliance with requirements in the root cause analysis and disclosure processes. Pharmacy Operations – Properly seal ceilings and install automatic door and light switches in clean rooms. \n\r 9/15/2008 http://www.va.gov/oig/CAP/VAOIG-08-01745-201.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 472 employees. The review covered eight operational activities and followed up on recommendations from the prior CAP review. The system complied with selected standards in the following two areas (1) patient satisfaction survey scores and (2) staffing. We highlighted positive achievements in implementing an emergency department (ED) display board, developing an operating room slider board, and developing evidence-based cancer patient management models. We made recommendations for improvements in the following activities: QM – Strengthen aspects related to data gathering, analysis, and the reporting process; documenting data analyses discussions; evaluating corrective actions taken; and monitoring the medication reconciliation process. Pharmacy Operations and Controlled Substances Inspections – Correct weaknesses related to program oversight, monthly inspections, and inspector competency assessments. Environment of Care – Address security and safety issues and implement corrective actions. ED and Urgent Care Center Operations – Comply with VHA and system policy and monitor patient transfers. Medication Management – Document pain medication effectiveness within the required timeframe.\n\rCoordination of Care –Document patient understanding of discharge instructions. \n\r 9/11/2008 http://www.va.gov/oig/52/reports/2008/VAOIG-07-02796-203.pdf he OIG conducted an audit to evaluate the effectiveness of controls over Veterans Health Administration’s (VHA) government purchase card practices. The objective of the audit was to determine if controls over VA medical facility practices prevented or detected questionable, improper, and potentially fraudulent purchase card transactions. In addition, the audit included an assessment of the price reasonableness of selected transactions. Generally, controls over VHA’s government purchase card practices effectively prevented questionable, improper, and potentially fraudulent purchase card transactions. In addition, of 707 audited purchase card transactions made by 11 medical facilities, 581 (82.6 percent) totaling $1,187,955 were considered to be reasonable priced. For the other 126 (17.4 percent) transactions totaling $799,997, cardholders did not maintain the documentation needed to confirm price reasonableness or ensure the most efficient use of funds. Controls needed improvement to ensure cardholders maintain adequate documentation of the receipt of goods and services and price reasonableness. In addition, controls needed strengthening to ensure medical facility compliance with policies addressing OIG reported deficiencies.\n\r 9/11/2008 http://www.va.gov/oig/54/reports/VAOIG-07-02599-199.pdf We conducted this inspection to review allegations that a patient was prematurely discharged, improperly monitored and treated, and assaulted by staff; and that medical staff failed to communicate with the patient’s family. We found that the patient had an uncomplicated recovery post-operatively and was appropriately discharged from the ICU to a medical-surgical unit. The medical-surgical unit staff appropriately monitored vital signs and clinical status. We did not find evidence that the patient was assaulted. We did not substantiate that the physicians were uncooperative in providing information or that staff intentionally withheld information from the patient’s family. However, at times the information provided was conflicted and sporadic, resulting in family frustration and mistrust of facility and staff. Initiating a palliative care consult would have been appropriate. \n\rWe recommended that management require that all physicians review existing palliative care policies to ensure that a palliative care consult is initiated whenever indicated. \n\r 9/10/2008 http://www.va.gov/oig/CAP/VAOIG-08-00777-200.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 312 system employees. The review covered seven operational activities. The system complied with selected standards in pharmacy operations and patient satisfaction. For discharge instructions, the system took corrective action while we were onsite; therefore, we made no recommendations for this activity. We identified two activities as organizational strengths, electronic medical record business rules and prosthetic modular foot design and development. We made recommendations for improvement in the following activities: QM – Improve the coordination of system-wide performance improvement activities and evaluate and disclose adverse events in accordance with Veterans Health Administration policy. Environment of Care– Require nursing staff to increase patient monitoring on the locked mental health unit and assure the security of confidential patient information.\n\r 9/10/2008 9/9/2008 http://www.va.gov/oig/52/reports/2008/VAOIG-08-01559-193.pdf 9/5/2008 http://www.va.gov/oig/54/reports/VAOIG-08-02346-191.pdf This review, on the use of a medication called varenicline (Chantix?) in a particular VA research study, followed an incident in which a veteran alleged that Chantix? caused him to become aggressive and engage in inappropriate activities. The Food and Drug Administration (FDA) had reported the possibility of an association with changes in mood, behavior, or suicidal thoughts and Chantix? on November 20, 2007. The FDA upgraded this warning to a public health advisory on February 1, 2008. Our review focused on the timeliness of patient notification following warnings from FDA, the adequacy of the informed consent process, and the reporting of adverse events. \n\rWe found that the facility Pharmacy Service responded appropriately to FDA communications in notifying providers of these newly defined risks. However, the Research Service did not ensure that patients with post-traumatic stress disorder (PTSD) who were also enrolled in a smoking cessation study received adequate and timely notice of these risks. We further found that the facility failed to ensure that patients in this study who had taken Chantix? signed an addendum to the consent form disclosing these risks. \n\rWe made nationwide recommendations regarding notification of all patients currently taking Chantix?, development of a mechanism to notify have Institutional Review Boards of FDA communications regarding medications involved in research protocols, and appropriate administrative action. We also made facility specific recommendations regarding data validation and auditing of active protocols involving human subjects.\n\r 8/28/2008 http://www.va.gov/oig/54/reports/VAOIG-08-01297-187.pdf The purpose of the review was to evaluate allegations regarding the post-traumatic stress disorder (PTSD) program. We concluded that the substantial presence of a clinician-administrator is needed to provide overall coordination and leadership for PTSD treatment. We recommended that a clinician-administrator be designated to provide overall PCT and PTSD program direction and leadership; relevant data sources be identified, updated, and coordinated to ensure that appropriate PTSD treatment conclusions can be made; follow-up patient contact procedures be performed consistently; and action is taken to enhance accessibility of PTSD therapies to OIF/OEF patients. 8/26/2008 http://www.va.gov/oig/CAP/VAOIG-08-00400-190.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). We also provided fraud and integrity awareness training to 269 medical center employees. This review covered six operational activities; we also followed up on recommendations from earlier reports. The facility complied with selected standards in the Survey of Healthcare Experiences of Patients activity. We identified the Under Secretary for Health’s Diversity Award in Workforce Development and Succession Planning as an organizational strength. We made a total of 20 recommendations for improvements in Quality Management, Environment of Care, Pharmacy Operations, Follow-Up on Background Investigations and Security Clearances, and Follow-Up on Moderate Sedation Practices. 8/26/2008 http://www.va.gov/oig/54/reports/VAOIG-08-01377-185.pdf The OIG reviewed the care of two West Virginia combat veterans who were being treated for severe post-traumatic stress disorder (PTSD) and who died in their sleep. Senator Rockefeller asked that the review take into account the medications prescribed and explore any pattern in these tragic deaths. The Chief Medical Examiner found that these patients died from combined drug intoxication involving prescribed and non-prescribed medications. VA’s Pharmacy Benefits Management program and its Center for Medication Safety conducted a nationwide data pull for the last 10 years of all-cause mortality for patients prescribed the combination of quetiapine, paroxetine, and clonazepam. Additional analyses examined other combinations of mental health medications, including an analysis by age of patients with and without PTSD. There was no apparent signal to indicate increased mortality for patients taking the combination of quetiapine, paroxetine, and clonazepam when compared with patients taking other similar combinations of psychotropic medications. We concluded that the clinical care provided for these patients at the Charleston community based outpatient clinic, and the VA facilities in Huntington and Cincinnati met community standards of care. The direct impact of non-prescribed medications in these patient deaths cannot be determined. VA mental health providers describe the use of non-prescription medications as growing area of concern in the treatment of young veterans. However, since returning war veterans may have multiple mental health conditions in addition to PTSD, we recommended that management evaluate exclusion criteria for admission related to medications for newly-diagnosed patients to the Residential PTSD Program. \n\r 8/14/2008 http://www.va.gov/oig/CAP/VAOIG-08-00988-181.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). We also provided fraud and integrity awareness briefings to 254 facility employees. The review covered four operational activities. The facility complied with selected standards in the following two areas (1) environment of care (EOC) and (2) survey of healthcare experiences of patients. We highlighted positive achievements in maintaining an exceptionally clean EOC and in the timeliness of root cause analysis. 8/13/2008 http://www.va.gov/oig/CAP/VAOIG-07-03174-184.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 314 system employees. The review covered five operational activities. The system complied with selected standards in the following three activities: (1) pharmacy operations, (2) QM program, and (3) survey of healthcare experiences of patients. We identified the system’s improved outpatient clinic access through system redesign as an organizational strength. We made recommendations for improvement in the following activities: Environment of Care – Ensure that managers initiate pest control measures, seal a hole between a nutrition kitchen and a housekeeping closet, clean bathrooms and showers regularly to prevent mold, replace standard screws with tamper-proof screws, reduce the risk of fires in clothes dryer vents, and eliminate potential exposure to secondhand smoke. Emergency Department and Urgent Care Centers – Ensure compliance with Veterans Health Administration and system policies governing inter-facility and \n\rintra-facility patient transfers.\n\r 8/13/2008 http://www.va.gov/oig/54/reports/VAOIG-07-01922-180.pdf We conducted an inspection to determine the validity of allegations concerning poor quality of care and inadequate oversight provided by the Community Nursing Home Program at VA North Texas Health Care System. We substantiated that ongoing patient monitoring and follow-up visits were not conducted every 30 days. We also substantiated that information for annual inspections and exclusion criteria were not consistently analyzed. \n\rWe recommended that management comply with Veterans Health Administration policy concerning 30-day follow-up visits and evaluating annual inspections and exclusion criteria. Management concurred with the findings and implemented acceptable action plans. \n\r 8/12/2008