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Healthcare Inspection – Primary Care Provider’s Clinical Practice Deficiencies and Security Concerns, Fort Benning VA Clinic, Fort Benning, Georgia

Report Information

Issue Date
Report Number
16-03405-80
VISN
State
Georgia
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
8
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted a healthcare inspection regarding clinical practice concerns and lack of security at the Fort Benning VA Clinic (Clinic), Fort Benning, GA, located at the U.S. Army Garrison, part of Central Alabama Veterans Health Care System (system). The complainant alleged that a Primary Care Provider (PCP X) did not follow up on elevated prostate-specific antigen (PSA) results, evaluate a patient’s condition, provide timely care, and respond to patient requests for specialty care/pharmacy services. The complainant also alleged the Clinic lacked VA Police and panic alarms. We substantiated that PCP X did not routinely follow up on elevated PSA results, which delayed a patient’s prostate cancer diagnosis and treatment. Also, system leaders did not consistently monitor PCP X’s performance or take adequate administrative action. We notified system and VISN 7 leaders about PCP X’s performance and compromised quality of care. Although we did not substantiate that PCP X failed to evaluate a patient’s condition, documentation was regularly inconsistent with presenting conditions, diagnoses, and treatment plans. PCP X did not consistently submit appropriate consultations, follow up on consultant recommendations, or include relevant information to support consultations as required by VHA policy. We substantiated that PCP X did not provide care for an unscheduled patient (another PCP provided care), failed to provide timely care for two patients, and did not respond to a specialty care request. We did not substantiate that PCP X failed to respond to pharmacy service requests. We substantiated the Clinic lacked VA Police, but U.S. Army Garrison police responded to calls. We substantiated the Clinic lacked panic alarms, which were not required. Clinic staff did not receive emergency procedures training or information. We made eight recommendations.

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 Veterans Integrated Service Network Director ensure that the System Director evaluates the care of the subject patient (Patient 1) and consults with the Office of General Counsel for disclosure to the patient, if appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Veterans Integrated Service Network Director ensure that the System Director consults with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action(s), if any, for Primary Care Provider X and Primary Care Provider X’s supervisors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that providers notify patients of test values and follow up on clinical laboratory results as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that providers accurately document patients’ assessment, diagnosis, and treatment information into the electronic health record.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that consults for VHA and non-VA care are entered and completed within time frames set by Veterans Health Administration.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that employees receive training appropriate for the assigned Workplace Behavioral Risk Assessment risk level.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that Clinic employees are trained in emergency management procedures.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that emergency procedures and contact information are posted and readily available to Clinic employees.