Report Summary

Title: Community Care Coordination Delays for a Patient with Oral Cancer at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
Report Number: 21-02326-233 Download
Issue Date: 9/12/2022
City/State: Fayetteville, AR
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Hotline Healthcare Inspection
Release Type: Unrestricted

The VA Office of Inspector General (OIG) conducted a healthcare inspection related to community care coordination delays for a patient with oral cancer at the Veterans Health Care System of the Ozarks (facility) in Fayetteville, Arkansas.

The OIG determined that the facility’s Office of Community Care (OCC) staff failed to schedule radical resection surgery within 30 days of an initial consult and failed to act or delayed taking action on five community care consults for the patient’s surgery. As a result, the patient’s surgery took place 205 days after the first consult was placed. Facility OCC staff could not provide an explanation for the failure to act or the delays.

The OIG substantiated that facility OCC staff failed to coordinate radiation therapy and delayed coordinating chemotherapy to begin within six weeks after surgery, as requested. Community hospital staff did not use a request-for-services form when seeking approval for the patient’s radiation therapy and chemotherapy evaluation appointment. Facility OCC staff denied the referral for radiation therapy at the community hospital, citing a lack of Veterans Health Administration OCC guidance on community care referrals. Although facility OCC staff entered a consult for chemotherapy at the facility, they failed to communicate the urgency of the care to facility oncology providers.

A facility oncology provider saw the patient nine weeks after surgery and documented changes to the patient’s oral cancer and that radiation therapy would not be beneficial. The patient was placed on palliative care and died.

The OIG made one recommendation to the Under Secretary for Health related to standardizing community care coordination for follow-up requests from the community provider and two recommendations to the Facility Director related to completing consults within the 30 days and coordinating oncology care in the community.

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