Alleged Poor Quality of Cancer Care at the VA Caribbean Healthcare System, San Juan, Puerto Rico

The VA Office of Inspector General (OIG) conducted an inspection to review an allegation of poor quality of cancer care to a community living center (CLC) patient, and to follow up on the adequacy and implementation status of action plan items to address deficiencies identified by Veteran Integrated Network (VISN) 8 reviewers related to the care of 55 patients at the VA Caribbean Healthcare System (facility) in San Juan, Puerto Rico. The OIG substantiated that staff inadequately monitored the CLC patient. Documentation was insufficient and there were no care coordination agreements between the CLC and other services. Licensed practical nurses did not add registered nurses as co-signers to notes to alert them of changes in the patient’s status, and the patient’s care plan had not been modified to include the initiation of chemotherapy. The OIG found that action plan items did not comprehensively address all findings identified by non-facility VISN reviewers. While not an allegation, the OIG found that VISN 8 had contracted with a non-Veterans Health Administration reviewer to independently review eight patient cases for interrater reliability; however, the information provided to the interrater reviewer was not identical to the information provided to the non-facility VISN reviewers. The OIG made one recommendation to the VISN Director related to clear and consistent instructions for concurrent management reviews and six recommendations to the Facility Director related to the monitoring of chemotherapy patients, care coordination agreements between the CLC and specialty services, utilization of procedures regarding the communication of patient status changes, completion and accuracy of patient care plans, primary care provider training on prostate cancer patient management, and addressing the findings of the non-facility VISN reviewers.