Quality of Care Concerns at Two Veterans Integrated Service Network 23 Facilities and a Veterans Readjustment Counseling Center

OIG conducted an inspection at the October 2014 request of Congressman Timothy J. Walz to assess quality of care concerns at the St. Cloud and Minneapolis Health Care Systems (St Cloud, Minneapolis); and the St. Paul Veterans Readjustment Counseling Center (Vet Center). We substantiated St. Cloud managers notified patients through a letter rather than individual contact when Mental Health (MH) services provided by a non-VA PTSD clinic were stopped in 2009. St. Cloud staff did not individually contact patients prior to terminating or transferring patients. Some veterans did not seek or receive MH services from VA. Also, we substantiated Minneapolis managers notified patients through a letter rather than individual contact when MH services provided by a non-VA PTSD clinic were stopped in 2014. However, the decision was rescinded approximately 3 months after sending the letters, and prior to the decision’s effectiveness date. We could not substantiate when the Vet Center contract for non-VA PTSD care was terminated in 2014, that a Vet Center staff member misled the vendor regarding termination. We did not find documentation that Vet Center staff successfully contacted all affected patients to arrange transfer back to the Vet Center or VA MH services. In addition, we did not substantiate a Minneapolis patient’s colonoscopy was untimely scheduled. We substantiated a Minneapolis patient’s x-ray of his foot was not scheduled timely but did not identify adverse effects related to the delay. We substantiated test results were not communicated timely to a Minneapolis patient. We did not find documentation that the patient experienced adverse effects due to the delay. We also substantiated a provider did not document consideration of a potentially significant adverse medication interaction when a patient’s medications were changed. However, the patient’s electronic health record did not contain documentation that the patient experienced adverse drug interactions. Minneapolis managers identified opportunities for improvement to ensure medication reconciliation was done consistently. We recommended (1) the St. Cloud Director ensure adequate processes for termination or transfer when non-VA MH services are discontinued and identify patients whose non-VA PTSD services were terminated, determine if the patients were offered and received MH treatment, and take action as appropriate; (2) the Minneapolis Director ensure compliance with VHA scheduling and communication of test results policies; and (3) the Chief of Vet Center Services review the patients whose non-VA PTSD services were terminated, determine if the patients were offered and received mental health services, and take action as appropriate.