Report Summary

Title: Opioid Safety at the VA Northern California Health Care System in Mather
Report Number: 22-00901-78 Download
Issue Date: 3/8/2023
City/State: Mather, CA
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) reviewed the Opioid Safety Initiative (OSI) oversight processes at the VA Northern California Health Care System (facility).

In an effort to evaluate the effectiveness of OSI oversight processes at the Veterans Health Administration (VHA), the OIG reviewed data of numerous providers across VHA. Several providers assigned to the facility’s Sacramento VA Medical Center were identified as prescribing “high dose” opioids. The OIG conducted a review of opioid therapy management practices by patient aligned care team providers (providers) and supervisors (supervisors) at the facility, in addition to facility and Veterans Integrated Service Network (VISN) oversight processes for opioid therapy.

The OIG determined that supervisors ensured that providers received training on OSI. Facility providers and supervisors implemented safe opioid therapy prescribing practices, including completing informed consents. Facility providers and supervisors completed risk mitigations for patients receiving opioid therapy, including state prescription drug monitoring and urine drug screens. For calendar year 2021, facility completion rates for patients prescribed opioid therapy met or exceeded the VISN performance goal for informed consents (97 percent), state prescription drug monitoring (99 percent), and urine drug screens (89.8–93.9 percent).

Facility providers had knowledge of VHA recommendations for a pain assessment to be completed every three months, with a completion rate of 73.6 percent over the last 100 days during the inspection.

Facility and the VISN had staff, committees, and teams as required to provide oversight and support integration of the OSI into primary care.

The facility did not have a required policy providing local guidance on state prescription drug monitoring and the facility pain management policy provided outdated guidance. The Facility Director concurred with the OIG’s two recommendations related to creating and updating the policies.

Last Updated: