Alleged Inappropriate Controlled Substance Prescribing Practices at a Veterans Integrated Service Network 20 Medical Facility

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to a complaint that a primary care provider (PCP1) at a Veteran Integrated Service Network (VISN) 20 Facility (Facility) continued to prescribe controlled substances to a patient at high-risk for overdose. The OIG substantiated that PCP1 was aware the patient was getting controlled substances from outside pharmacies and had a history of benzodiazepine abuse, and family members reported that the patient was abusing controlled substances. The OIG substantiated that PCP1 prescribed the patient controlled substances when he was no longer the patient’s designated PCP and despite nonadherence to an Opioid Agreement. The OIG could not substantiate that PCP1 had a reputation among Facility staff of prescribing narcotics “recklessly.” The OIG did not substantiate that providers warned PCP1 about his prescribing practices. The OIG reviewed the Facility’s processes, policies, and procedures about controlled substance prescribing and identified limitations in controlled substance prescribing oversight. The Facility did not have regular processes in place for reviewing controlled substance prescribing for individual patients. The Facility lacked formalized processes and referral mechanisms for interdisciplinary collaboration for patients with complex clinical pain. The Facility had policies for state prescription drug monitoring programs (PDMP) and urine toxicology screens, although no mechanisms to monitor provider responses to positive PDMP and toxicology results. The Facility Board that is responsible for controlled substance safety oversight responsibility for patient record flags was not well defined and lacked established protocols and procedures. The Facility did not comply with the Veterans Health Administration’s peer review directive. The OIG made one recommendation to the VISN Director to review the patient’s care and provider’s practice and seven recommendations to the Facility Director related to prescribing practices and peer review processes.