Report Summary

Title: Audiology Leaders’ Deficiencies Responding to Poor Care and Monitoring Performance at the Eastern Oklahoma VA Health Care System in Muskogee
Report Number: 20-04341-182 Download
Issue Date: 7/21/2021
City/State: Muskogee, OK
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspection
Release Type: Unrestricted

The OIG conducted this healthcare inspection after receiving information from the facility that an audiologist had provided poor care and billed for unrendered services. The inspection focused on actions the Audiology Supervisor, Service Chief, and Chief of Staff (audiology leaders) took in response to the audiologist’s poor clinical care. A facility fact-finding review revealed the audiologist provided poor care to eight of 43 patients reviewed, including misinforming patients who needed hearing aids that hearing aids were not needed.

Although the audiology leaders reported the fact-finding results to the OIG, they failed to evaluate whether patients needed clinical follow-up; determine whether additional patients were affected by the audiologist’s poor care; evaluate whether clinical disclosures were required for the affected patients; and communicate the fact-finding results to the Facility Director, who was therefore unable to initiate the process to determine the necessity of a large scale disclosure.

The instances of poor care were also not reported to the Patient Safety Manager who was, as a result, unable to assess the adverse events to determine if patient safety interventions were indicated.

The OIG also found that performance monitoring of facility audiologists was not conducted as required. Annual competency assessments and annual performance appraisals were not consistently completed and did not contain adequate performance standards.

Audiology leaders failed to consider whether the audiologist’s actions warranted a report to the state licensing board due to a lack of understanding of the requirements for reporting and, therefore, the Facility Director was not informed of the need to initiate a state licensing board review.

The OIG made 10 recommendations to the Facility Director related to ensuring patients affected by poor audiology care receive follow-up and disclosures as appropriate, overseeing audiologists, and ensuring audiology leaders’ compliance with policies regarding disclosure, adverse event reporting, and state licensing board reporting.