Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2020

Report Information

Issue Date
Report Number
21-01507-61
VISN
State
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
National Healthcare Review
Report Topic
Patient Safety
Mental Health
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program report provides a focused evaluation of VHA facilities’ selected requirements and guidelines for medication management. This evaluation focused on compliance with program requirements and processes related to long-term opioid use for pain. This report describes medication management findings from healthcare inspections initiated at 36 VHA medical facilities from November 4, 2019, through September 21, 2020. Each inspection involved interviews with facility leaders and staff and reviews of clinical and administrative processes. The results in this report are a snapshot of VHA performance at the time of the fiscal year 2020 OIG reviews. The OIG found general compliance with many of the selected requirements. However, the OIG identified weaknesses with • aberrant behavior risk assessments, • concurrent benzodiazepine therapy, • urine drug testing, • informed consent, • patient follow-up, and • quality measure oversight.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers complete aberrant behavior risk assessments on all patients prior to initiating long-term opioid therapy.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers communicate problematic urine test results to patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers follow up with patients within three months after initiating opioid therapy to assess adherence to the pain management plan of care and effectiveness of interventions.
No. 7
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities monitor the quality of pain assessment and effectiveness of pain management interventions.