http://www4.va.gov/oig/rss/reports-rss.asp Official reports of the VA Office of Inspector General en-us Copyright 2010 VA Office of Inspector General http://www4.va.gov/oig/rss Tue, 09 Feb 2010 18:04:01 EST VAOIGWebmasters@va.gov (VAOIG Webmasters) Fri, 05 Feb 2010 00:00:00 EDT http://www.va.gov/oig/54/reports/VAOIG-09-01110-81.pdf http://www.va.gov/oig/54/reports/VAOIG-09-01110-81.pdf OHI reviewed allegations that veterans at VA Austin Outpatient Clinic (OPC) in Texas (part of Central Texas Veterans Health Care System) have been charged for treatment that was related to Military Sexual Trauma (MST) treatment. Erroneous copayments for MST-related care occurred because staff inappropriately changed patients’ copayment status from “not required to make a copayment” to “copayment required”, without reviewing for an MST designation. In addition to educating staff on the process for reviewing MSTs prior to adding charges, the standard operation procedure should require staff to establish a process to check for the practice in an established on-going quality assurance activity. CTVHCS managers cancelled all erroneous charges and refunded the patients any payments received. \n\rWe recommended that the Acting Under Secretary for Health ensure: an appropriate control process or procedure is in place at all facilities to prevent erroneous copayment charges, that facility Directors educate staff on the process for reviewing for MST prior to adding copayment charges, that facility Directors include in their Standard Operation Procedure the requirement that staff review for an MST designation prior to adding charges and establish an on-going quality assurance activity to monitor the practice, and that facility Directors educate providers to not designate care or medication as related to MST unless the care or medication is provided for MST related conditions. The Acting Under Secretary for Health, VISN 17 Director, and CTVHCS Director concurred with the findings and recommendations and provided implementation plans. \n\r Thu, 04 Feb 2010 00:00:00 EDT http://www.va.gov/oig/CAP/VAOIG-09-03298-80.pdf http://www.va.gov/oig/CAP/VAOIG-09-03298-80.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we also provided fraud and integrity awareness briefings to 225 employees. The review focused on eight operational activities. We made recommendations for improvement in all of the following activities: Environment of care. QM. Physician credentialing and privileging. Medication management. Magnetic resonance imaging safety. Contracted/agency registered nurses. Coordination of care. Medical center policies.\n\r Tue, 02 Feb 2010 00:00:00 EDT http://www.va.gov/oig/CAP/VAOIG-09-03613-74.pdf http://www.va.gov/oig/CAP/VAOIG-09-03613-74.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 30 employees. The review covered seven operational activities. The system complied with selected standards in the following three activities: (1) contracted/agency registered nurses, (2) coordination of care, and (3) medication management. We identified the system’s Executive Dashboard as an organizational strength. We made recommendations for improvement in the following four activities: QM. Physician credentialing and privileging. Magnetic resonance imaging safety. Environment of care.\n\r Wed, 27 Jan 2010 00:00:00 EST http://www.va.gov/oig/CAP/VAOIG-09-03272-70.pdf http://www.va.gov/oig/CAP/VAOIG-09-03272-70.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 302 employees. The review covered six operational activities. The medical center complied with selected standards in medication management. We identified re-admission rates of patients with congestive heart failure and medication wall carts as organizational strengths. We made recommendations for improvement in the following five activities: QM. Physician credentialing and privileging. Environment of care. Coordination of care. Magnetic resonance imaging safety.\n\r\n\r Mon, 25 Jan 2010 00:00:00 EST http://www.va.gov/oig/CAP/VAOIG-09-03742-73.pdf http://www.va.gov/oig/CAP/VAOIG-09-03742-73.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 187 employees. The review covered six operational activities. The system complied with selected standards for physician credentialing and privileging. We identified daily access reports and identification of fire extinguishers on the locked mental health unit as organizational strengths. We made recommendations for improvement in the following five activities: Environment of care. Medication management. Coordination of care. QM. Contracted/agency registered nurses.\n\r\n\r Mon, 25 Jan 2010 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-01047-69.pdf http://www.va.gov/oig/54/reports/VAOIG-09-01047-69.pdf The purpose of this review was to determine the validity of allegations regarding inadequate telemetry heart monitoring practices and lack of staff training that related to two patient deaths. We concluded that both patients had multiple medical problems that contributed to their deaths, and it would be difficult to determine whether delays in response to abnormal cardiac rhythms led to their demise. We did not substantiate the allegation that the deaths were a result of inadequate telemetry monitoring or lack of staff training. We substantiated the allegation that management had been informed of problems with the telemetry program prior to the patient deaths and had not identified a clear course of action or assigned responsibility to address concerns raised. We substantiated the allegation that there were competency and training issues with medical support assistants and registered nurses assigned to telemetry. Temporary measures were enacted to ensure safe patient care following the first patient’s death. Managers concurred with our recommendations to evaluate the telemetry program, require that all staff complete competency assessments and that training be provided as needed to maintain competency, and that there be clinical oversight of medical support assistants. Thu, 21 Jan 2010 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-03418-68.pdf http://www.va.gov/oig/54/reports/VAOIG-09-03418-68.pdf This report reviewed allegations regarding a pattern of inappropriate medical coding and billing to increase third party insurance reimbursements at the Kansas City VA Medical Center. The allegation included two specific incidents: (1) the Medical Care Collection Fund Billing Department inappropriately added a Current Procedural Terminology “modifier 59” to the billing records for a patient receiving “Epoetin” injections, (2) and the Billing Department inappropriately billed for complications attributable to the patient’s participation in a voluntary research study. We were unable to substantiate the allegations and make no recommendations.\n\r Wed, 20 Jan 2010 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-02988-66.pdf http://www.va.gov/oig/54/reports/VAOIG-09-02988-66.pdf OIG conducted an inspection in response to allegations that a surgeon had poor infection control practices, a higher incidence of MRSA, altered records to reflect lower procedure blood loss, and performed surgery on a patient who developed significant complications at the Huntington VA Medical Center, Huntington, West Virginia. We did not substantiate allegations made against the surgeon; however, we did identify a lack of integration of infectious disease information between surgical services, NSQIP, Infection Control, and MRSA programs. We recommended that trended and analyzed infection control data be provided to key committee members and clinical managers. Tue, 19 Jan 2010 00:00:00 EST http://www.va.gov/oig/CAP/VAOIG-09-03039-62.pdf http://www.va.gov/oig/CAP/VAOIG-09-03039-62.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 71 employees. This review focused on seven operational activities. The system complied with selected standards in magnetic resonance imaging safety. We identified the discharge call program and provider dashboard as organizational strengths. We made recommendations for improvements in the following six activities: QM. Physician credentialing and privileging. Coordination of care. Environment of care. Medication management. Contracted/agency registered nurses.\n\r\n\r Thu, 14 Jan 2010 00:00:00 EST http://www.va.gov/oig/52/reports/2010/VAOIG-09-01995-63.pdf http://www.va.gov/oig/52/reports/2010/VAOIG-09-01995-63.pdf The Benefits Inspection Program conducts inspections at VA Regional Offices (VAROs) to review disability compensation claims processing and Veterans Service Center (VSC) operations. \n\rThe Roanoke VARO management team faces challenges in providing benefits and services to veterans. The Roanoke VARO challenges include addressing oversight of operational activities, acquiring space to support adequate storage of large filing cabinets containing veterans’ claims folders, associating claimant evidence with the veterans’ claims folders, and providing training to staff. The VARO did not meet requirements for 6 of 14 operational areas reviewed. The VARO management team needs to provide additional oversight and training of personnel responsible for processing claims identified as traumatic brain injury (TBI), herbicide exposure, and Haas cases. Additionally, management needs to improve controls over the safeguarding of veterans’ personally identifiable information (PII), handling of claims-related mail, and responding to electronic inquiries. We recommended that the VARO coordinate with VA contracted medical staff to ensure medical examiners use the most current examination worksheet when evaluating disabilities associated with TBI. In addition, we recommended the VARO improve oversight to ensure proper safeguards of veterans’ PII, improve mail-handling procedures in the Triage team, and improve oversight of electronic responses to veterans. Further, the VARO needs to acquire adequate space to store and safeguard veterans’ claims folder. The Director of the Roanoke VARO concurred with all recommendations. The management team’s planned actions are responsive and we will follow-up as required on all actions.\n\r\n\r Thu, 14 Jan 2010 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-02987-60.pdf http://www.va.gov/oig/54/reports/VAOIG-09-02987-60.pdf The purpose of this inspection was to determine the validity of the allegations regarding the quality of mental health care provided to a patient. We could not find evidence in the medical record documentation that the provider sufficiently explored relevant aspects of the patient’s recent suicidal thoughts and or further inquired about the location of the patient’s gun. Primary Care Service did not provide the patient with a mental health consult within the required timeframe and did not facilitate further assessment of the patient’s mental health when he presented to the CBOC for unscheduled visits with mental health issues. Although we identified these patient care issues, given all the facts in this case, including those relating to the care provided to this patient both at VA and at non-VA facilities, we cannot conclude that these deficiencies impacted the patient’s outcome. We recommended that managers: (1) require documented discussion in the patient’s medical record regarding access to lethal weapons for patient’s determined by the evaluating clinician to be at heightened risk for suicide; (2) require newly hired providers are initially monitored through chart review to assure new staff are sufficiently adept with use of CPRS, (3) assure patients seen in the primary care clinic and who have mental health needs receive timely referrals; and assure that clinical staff facilitate further assessment of patient’s mental health care needs for patients who present to primary care for unscheduled visits where mental health issues are central to the visit. Management submitted appropriate implementations.\n\r Wed, 13 Jan 2010 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-02470-61.pdf http://www.va.gov/oig/54/reports/VAOIG-09-02470-61.pdf The purpose of this review was to determine the validity of allegations regarding management decision impacting patient care and work environment. Three of the allegations resulted in recommendations to the VISN and Medical Center Directors. We recommended that: (1) actions be taken to reduce the scanning backlog and establish a process to assure timely entry of significant information in patients’ electronic medical records, (2) managers initiate a review of registered nurse staffing to ensure coverage of the Emergency Department and Nursing Officer of the Day, and (3) the Medical Center Director communicates, orally and in writing, organizational changes to all employees and that administrative supervisory lines are clearly written and effected in official personnel actions. Wed, 13 Jan 2010 00:00:00 EST http://www.va.gov/oig/CAP/VAOIG-09-03313-59.pdf http://www.va.gov/oig/CAP/VAOIG-09-03313-59.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 302 employees. This review focused on six operational activities. The system complied with selected standards in the following four activities: (1) coordination of care, (2) magnetic resonance imaging safety, (3) physician credentialing and privileging, and (4) QM. We identified the management of veterans’ belongings and podiatry access as organizational strengths. We made recommendations for improvements in the following two activities: Medication management. Environment of care\n\r Mon, 11 Jan 2010 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-02950-58.pdf http://www.va.gov/oig/54/reports/VAOIG-09-02950-58.pdf The purpose of this review was to determine the validity of allegations of poor communication between the surgeon and the patient/family, delay in dialysis treatment, improper medical record documentation, failure to provide requested medical records, inappropriate use of restraints and continued medication despite evidence of adverse reaction. We concluded that there were deficiencies in this patient’s care that warranted consideration of institutional disclosure to the family. We did not substantiate the complainant’s allegation that surgical residents performed surgery without the family’s knowledge. We substantiated the allegation that dialysis was delayed; however, the medical center now provides in-house dialysis, and a nephrologist is on call at all times. We substantiated the allegation that some of the patient’s medical care was improperly documented. The medical record did not support statements made in an addendum to the discharge summary. We did not substantiate the allegation that a late entry into the electronic medical record was not marked as such, since all entries are automatically timed and dated. We did not substantiate the allegations that: complete medical records were not provided as requested, restraints were improperly used, and a medication was not discontinued despite a possible adverse reaction. Managers concurred with our recommendation to review this case with Regional Counsel to determine whether disclosure was managed appropriately. Thu, 07 Jan 2010 00:00:00 EST http://www.va.gov/oig/CAP/VAOIG-09-02921-57.pdf http://www.va.gov/oig/CAP/VAOIG-09-02921-57.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). This review focused on seven operational activities. The system complied with selected standards in the following three activities: (1) coordination of care, (2) environment of care, and (3) magnetic resonance imaging safety. We identified the Employee Influenza Program as an organizational strength. We made recommendations for improvements in the following four activities: QM. Medication management. Physician credentialing and privileging. Contracted/agency registered nurses. Tue, 05 Jan 2010 00:00:00 EST http://www.va.gov/oig/CAP/VAOIG-09-03550-55.pdf http://www.va.gov/oig/CAP/VAOIG-09-03550-55.pdf The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we provided fraud and integrity awareness training to 644 employees. This review focused on six operational activities. The medical center complied with selected standards in the following two activities (1) medication management and (2) physician privileging. We identified the patient transfer center, the Prosthetic/Orthotic Laboratory, and inpatient diabetes care as organizational strengths. We made recommendations for improvements in the following four activities: magnetic resonance imagining safety, QM, coordination of care, and environment of care.\n\r Wed, 30 Dec 2009 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-02589-54.pdf http://www.va.gov/oig/54/reports/VAOIG-09-02589-54.pdf The purpose of the review was to determine the validity of the following allegations: (1) lack of collaboration, inappropriate care, and deaths; (2) unwarranted amputations; and (3) inappropriate management of vein patients. We substantiated poor collaboration between Interventional Radiology and Vascular Surgery for two of the four patients but concluded that this did not directly contribute to the fatal outcomes. We concluded that the system took appropriate actions to review the quality of care and make system improvements, which included conducting institutional disclosures in two of the four cases. However, we determined that the system needed to refer a case to Regional Counsel for guidance. We did not substantiate the occurrence of unwarranted amputations or inappropriate management of vein patients. We recommended that the system refer Patient Case 2 to Regional Counsel to determine whether the system has an obligation to report the providers to the National Practitioner Data Base. Since management had already addressed the issue, we consider this recommendation closed. Mon, 28 Dec 2009 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-03245-53.pdf http://www.va.gov/oig/54/reports/VAOIG-09-03245-53.pdf The purpose of this inspection was to determine the validity of allegations regarding the care provided to a patient who died within 24 hours of admission to the North Chicago VA Medical Center (VAMC), North Chicago, Illinois. The complainant suggested that a medical trainee may have been inadequately supervised. We found the quality of care reviews conducted by the VAMC to be thorough. Although we found deficiencies in the quality of care provided for this patient, we did not demonstrate a connection with the patient’s death. We recommended that managers evaluate this case with Regional Counsel for possible disclosure to the patient’s family. We also recommended that staff comply with the VAMC’s policy for rapid intervention in patients with deteriorating clinical conditions. Management submitted appropriate implementation plans. Tue, 22 Dec 2009 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-01348-49.pdf http://www.va.gov/oig/54/reports/VAOIG-09-01348-49.pdf The purpose of this review was to determine the validity of allegations regarding a delay in cancer diagnosis, treatment, and determine whether staff disclosed the adverse event to the patient. We substantiated that there was a delay in cancer diagnosis and treatment, a radiologist failed to identity a lung nodule, the primary physician failed to follow up on the lung nodule, and a second radiologist failed to notify the primary physician. We also substantiated that staff initially failed to disclose the adverse event to the patient. We recommended that managers conduct a formal peer review and root cause analysis on all activities involving care of the identified patient, staff adhere to VHA and local incident reporting and adverse event disclosure policies and procedures, and managers consult Regional Counsel regarding disclosure to the family and explanation of rights. Mon, 14 Dec 2009 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-02397-48.pdf http://www.va.gov/oig/54/reports/VAOIG-09-02397-48.pdf The VA Office of Inspector General reviewed allegations regarding quality of care complaints in the emergency department (ED) at the Central Arkansas Veterans Health Care System, Little Rock, Arkansas. We did not substantiate that the patient was inadequately diagnosed and treated for severe abdominal pain. We found that clinicians appropriately treated the patient’s pain and ordered the correct treatments based on laboratory and imaging tests. We did not substantiate that the patient was placed in a locked room where no one checked on him for over 6 hours. The patient was discharged and allowed to sleep in a bed adjacent to the ED because he had no transportation home until the next morning. Staff checked on him several times during the night. We were unable to substantiate or refute that someone told the patient’s wife he had been discharged but they did not know where he was located. To reinforce effective communication with families, the Medical Center Director issued a memorandum while we were onsite. We made no recommendations. Fri, 11 Dec 2009 00:00:00 EST http://www.va.gov/oig/54/reports/VAOIG-09-02985-46.pdf http://www.va.gov/oig/54/reports/VAOIG-09-02985-46.pdf The purpose of this review was to determine the merit of allegations that a veteran was denied access to care at a community based outpatient clinic and whether that same veteran was not diagnosed or treated for lip cancer and decreased renal function. We did not substantiate that the veteran was denied care. We did not substantiate that that the lip cancer or decreased renal function were not diagnosed or treated. We made no recommendations. Thu, 10 Dec 2009 00:00:00 EST