Report Summary

Title: Review of Alleged Use of Inappropriate Wait Lists for Group Therapy and Post Traumatic Stress Disorder Clinic Team, Eastern Colorado Health Care System
Report Number: 17-00414-376 Download
Report
Issue Date: 11/16/2017
City/State: Alamosa, CO
Aurora, CO
Burlington, CO
Colorado Springs, CO
Golden, CO
La Junta, CO
Lamar, CO
Pueblo, CO
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Audits and Evaluations
Report Type: Audits, Reviews & Evaluations
Release Type: Unrestricted
Summary:

In September 2016, a complainant and letters from several Senators and Representatives alleged the Eastern Colorado Health Care System (ECHCS) used unofficial wait lists for group therapies. Also alleged was that the Colorado Springs Community Based Outpatient Clinic did not take timely action on Post Traumatic Stress Disorder Clinic Team (PCT) consults and falsified medical documentation following a veteran’s suicide.

We substantiated ECHCS staff improperly used unofficial wait lists for group therapies. This occurred because management misinterpreted national guidance. As a result, management did not have access to accurate wait times and lacked assurance that staff scheduled all requests. We substantiated PCT staff did not timely process consults. In fiscal year 2016, staff did not initiate scheduling within VHA’s goal of 7 days for an estimated 38 percent of consults or provide care within VHA’s goal of 30 days for an estimated 64 percent of consults. We determined PCT staff inaccurately recorded dates for calculating wait times for an estimated 91 percent of consults that resulted in care, and improperly closed an estimated 40 consults without adequate documentation of scheduling efforts. These conditions occurred for a variety of reasons, including that PCT staff didn’t prioritize consult processing, have sufficient staffing resources, properly record dates, or always record scheduling attempts as required. As a result, veterans experienced underreported delays by an estimated 50 days for initial treatment, and management did not have assurance that staff attempted to schedule all veterans. For an estimated 210 consults, veterans were inappropriately denied the Veterans Choice Program. We did not substantiate Colorado Springs PCT staff falsified medical records. We reviewed medical documentation, interviewed the complainant, and ensured that the Office of Healthcare Inspections reviewed the records.

We recommended the ECHCS Director ensure staffing resources are sufficient and staff follow policy when scheduling. The ECHCS Director concurred with all recommendations and provided corrective actions. We closed two recommendations and will monitor remaining corrective actions.