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.
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.
Review of Unauthorized System Interconnection at the VA Regional Office in Wichita, Kansas
The VA Office of Inspector General (OIG) Hotline Division received an allegation that an unauthorized system interconnection existed between a Veterans Service Organization (VSO) network and the Wichita, KS, VA Regional Office (VARO). More specifically, the allegation stated that a system interconnection existed without a required Interconnection Security Agreement in place to define applicable information security requirements. The complaint also stated that the system interconnection was not disclosed to the OIG during a recent Federal Information Security Modernization Act audit. We substantiated the allegation that an unauthorized system interconnection existed between the Wichita VARO and the Kansas Commission on Veterans Affairs Office network. We also substantiated the allegation that the system interconnection was not disclosed to the OIG because Office of Information Technology (OI&T) staff did not believe the connection constituted a formal system interconnection according to VA policy. The unauthorized system interconnection occurred because OI&T technical staff did not have the technical knowledge or exercise due diligence to identify the system interconnection in accordance with VA policy; OI&T technical staff did not follow VA’s change management procedures for reviewing and approving significant network and system changes; and Wichita VARO did not have a formal process in place for managing VSO system change requests that may adversely affect VA’s network environment. As a result, the unauthorized system interconnection violated VA policy and the computers used by VSO representatives were inappropriately allowed to use client software to establish simultaneous network connections between VA’s and the VSO’s networks. We recommended the Assistant Secretary for Information Technology, in conjunction with the Wichita VARO facility director, ensure that the network interconnection with the Kansas Commission of Veterans Affairs is brought into compliance with VA information security requirements. The Principal Deputy Under Secretary for Benefits and the Acting Assistant Secretary for Office of Information and Technology concurred with our findings and recommendations. We will follow up on the implementation of corrective actions.