Healthcare Inspection – Alleged Patient Deaths and Management Deficiencies in Home Based Primary Care, Beckley VA Medical Center, Beckley, West Virginia

OIG conducted an inspection at the request of former Congressman Nick J. Rahall to assess the merit of allegations made by a complainant regarding patient deaths and management deficiencies in the Home Based Primary Care (HBPC) program at the Beckley VA Medical Center, in Beckley, WV. We substantiated that from 2007 through 2012, 25 of 40 patients died while awaiting admission to HBPC. However, we did not find that these patient deaths were associated with a delay in admission to HBPC, as the patients continued to receive care from other health care providers prior to their deaths. We found that from 2008 through July 2012, HBPC staff kept an unapproved wait list in violation of Veterans Health Administration policy. We did not substantiate that HBPC patient scheduling, wait times, and backlogs were mismanaged. We found that, other than the wait list issue cited above, HBPC program managers substantially complied with VHA and facility policies. We substantiated that an HBPC provider changed a patient’s diagnosis by adding a diabetes diagnosis to the patient’s problem list. However, we could not determine that the change was made to obtain prosthetic shoes for the patient. We did not substantiate that HBPC providers inappropriately prescribed antibiotics. We did not substantiate that providers overprescribed opioids or changed patients’ diagnoses in order to prescribe opioids. We made no recommendations.