Interim Summary Report - Healthcare Inspection - Patient Safety Concerns at the Washington DC VA Medical Center, Washington, DC
On March 21, 2017, a confidential complainant forwarded to the Office of Inspector General (OIG) documents describing equipment and supply issues at the Washington D.C. VA Medical Center (the Medical Center) sufficient to potentially compromise patient safety. OIG promptly reviewed the documentation. On March 29, 2017, OIG deployed a Rapid Response Team to assess the allegations. OIG’s team conducted interviews, collected documents, and conducted a physical inspection of the Medical Center’s satellite storage areas on March 29–30, 2017. The team returned for an additional site visit on April 4–6, 2017, and is on-site for a third inspection at the time of this report’s publication. OIG has preliminarily identified a number of serious and troubling deficiencies at the Medical Center that place patients at unnecessary risk. Although we have not identified at this time any adverse patient outcomes, we have found other issues. At least some of these issues have been known to the Veterans Health Administration (VHA) senior management for some time without effective remediation. Although our work is continuing, we believed it appropriate to publish this Interim Summary Report given the exigent nature of the issues we have preliminarily identified and the lack of confidence in VHA adequately and timely fixing the root causes of these issues. We are also including recommendations for immediate implementation.
Mr. Chairman, Ranking Member Schatz, and Members of the Subcommittee, thank you for the opportunity to discuss the Office of Inspector General’s (OIG) recent work on the operations of the Department of Veterans Affairs’ (VA) Veterans Crisis Line (VCL). My statement will discuss two OIG reports, one from March 2017, Healthcare Inspection – Evaluation of the Veterans Health Administration Veterans Crisis Line, and one from February 2016, Healthcare Inspection – Veterans Crisis Line Caller Response and Quality Assurance Concerns, Canandaigua, New York.
OIG Monthly Highlights
CONGRESSIONAL TESTIMONY Inspector General Delivers Testimony on Importance, Value of OIG Oversight The Honorable Michael J. Missal testified before the Subcommittee on Military Construction, Veterans Affairs, and Related Agencies, Committee on Appropriations, United States House of Representatives, on the oversight the Office of Inspector General (OIG) provides to VA programs and operations. Mr. Missal highlighted the more significant aspects of the OIG’s mission, vision, and values and discussed a number of recent or planned operational enhancements initiated since becoming Inspector General (IG) that are intended to better focus OIG efforts on high-risk areas throughout VA in a more proactive and timelier manner. Additionally, he discussed the OIG’s fiscal year (FY) 2017 operating budget, our FY 2018 request, and the anticipated effects of the Federal hiring freeze on the OIG’s operation. Lastly, he highlighted a number of recent OIG reports demonstrating VA’s susceptibility to fraud, waste, abuse, and mismanagement in its programs and operations. Given the historical average of a return on investment of $30 for every $1 expended on OIG oversight, Mr. Missal emphasized the need for the OIG to be positioned to conduct effective oversight.
SCM True Air Technologies, Of Ohio And Kentucky, And Its Former Company President - Guilty Of Delivering Misbranded Medical Devices From Unregistered Facilities To A Georgia V.A. Medical Center And Obstructing An FDA Investigation Into Their Conduct
Two men plead guilty to selling unregistered, misbranded, and defective bariatric beds to VA.
Operators of Trucking School Charged with Defrauding VA by Collecting Tuition for Veterans who Never Attended Classes
Two men arrested and indicted on federal charges that they defrauded the VA of over $4 million in tuition and other payments. The men are accused of falsely certifying that veterans attended classes at a trucking school.
Inventory Management and Staffing Deficiencies at the Washington, DC, VA Medical Center That Are Placing Patients at Unnecessary Risk
The VA Office of Inspector General issued an Interim Summary Report about inventory management practices and staffing deficiencies that place patients at unnecessary risk at the Washington, DC, VA Medical Center.
VA Office of Inspector General Enhances Healthcare Inspection Program
OIG’s new Comprehensive Healthcare Inspection Program (CHIP) reviews of Veterans Health Administration facilities starts in April 2017.