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Healthcare Inspection – Quality of Care Concerns in the Management of a Hepatitis C Patient, Grand Junction Veterans Health Care System, Grand Junction, Colorado

Report Information

Issue Date
Report Number
15-01599-289
VISN
State
Colorado
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
1
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted a review to assess quality of care concerns in the management of a Hepatitis C patient at the Grand Junction Veterans Health Care System, Grand Junction, Colorado. We substantiated the allegation that follow-up care was inadequate and led to further hospitalization. The Hepatitis C Care Provider often did not provide the care or assess the patient thoroughly when seen. The circumstances of discontinuity of care and the lack of a thorough analysis of the patient’s condition may have contributed to his progressive decline and slower recovery. Although not part of the original allegations, we also found that contingency plans were not in place to account for reduced availability of the Hepatitis C Care Provider as he started to decrease his hours. We did not substantiate that a non-qualified physician provided Hepatitis C treatment. Neither VA policy nor general practice regarding physicians’ credentialing and privileging, ongoing professional practice evaluations, and documentation of education hours require that clinicians have specific evidence of competency to manage Hepatitis C patients. We did not substantiate that the patient should have been admitted earlier to the hospital based on laboratory results. We found that the patient had an elevated ammonia level that was acknowledged timely and appropriately treated with medication. We made one recommendation.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure adequate consultation, formalized back up, and contingency plans for specialties with limited specialty provider availability.