Report Summary

Title: Falsification of Blood Pressure Readings at the Danville Community Based Outpatient Clinic, Salem, VA
Report Number: 18-05410-62 Download
Issue Date: 1/29/2019
City/State: Salem, VA
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) identified a primary care provider who appeared to have falsely documented patients’ blood pressure readings at the Danville Community Based Outpatient Clinic (CBOC) of the Salem VA Medical Center (facility), Virginia. The CBOC is a contracted clinic staffed and operated by Valor Healthcare, Inc. In a preliminary review, OIG inspectors identified that the provider repeatedly documented blood pressure rechecks of 139/89. The OIG immediately notified the facility’s Chief of Staff (COS) and recommended a comprehensive analysis be done to evaluate the extent of the 139/89 entries.

In an expanded review, the OIG determined the provider had not only falsified repeat blood pressure readings (readings higher than 139/89 would have required additional follow-up), but also failed to provide hypertension management to patients with initially elevated blood pressure readings. An OIG physician found limited evidence of interventions, treatment plan adjustments, medication changes, or close follow-up.

Further, the OIG found the COS’s initial response to be troubling. Despite being told of the concerns, it was not until the OIG team contacted the COS eight weeks later that the facility began an in-depth review of the provider’s documentation practices and management of patients with hypertension.

Multiple factors allowed the provider’s falsification of blood pressure readings to continue unabated, including lack of facility processes to validate the accuracy of performance measure data impacting monitoring reports. In addition,

• None of the Valor Healthcare employees with knowledge of the falsified blood pressure documentation shared their concerns with staff positioned to take corrective action, and

• Neither the facility nor Valor Healthcare were meeting aspects of the contract.

The OIG made five recommendations related to patient care follow-up, data integrity, policy and procedure development, leadership responsiveness, and contract-related training.