Report Summary

Title: Healthcare Inspection - Alleged Inadequate Oversight at a Contracted Homeless Program, VA New Jersey Health Care System, East Orange, New Jersey
Report Number: 12-01344-243
Issue Date: 7/16/2013
City/State: East Orange, NJ
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted
Summary: The OIG conducted an inspection in response to allegations that Community Hope, Inc. (CH agency) and the Veterans in Early Transitions Services (VETS) Program: Contributed to the death of a veteran because of a case manager’s negligence and lack of supervision; Lacked supportive services promised to stabilize veterans; Made inappropriate referrals for revenue generation based on payment earned for veteran-occupied beds; Provided inadequate breakfasts for their patients; Mismanaged medication causing some homeless veterans to overdose; Violated CH agency policy by inappropriately discharging patients, for reasons which included positive substance abuse screening, rendering them homeless; Employed non-experienced staff for the population being served and employed a leader who did not have the education and experience required by the VA housing contract. We did not substantiate the complainant’s allegations, we found that following the two patients’ deaths, the facility initiated a collaborative root cause analysis (RCA) with the CH agency. We concurred with the RCA team’s findings, recommendations, and actions taken. We found that the CH agency and facility staff made improvements to the VETS Program referral and admission process, patient supervision, monitoring, and safety. Furthermore, our interviews with VETS Program patients showed that they all had positive comments about their experience in the program. We made no recommendations.