Inside Oversight

In this episode of Inside Oversight, Nicole Maxey, a nurse consultant with the Office of Healthcare Inspections, discusses the VA OIG’s evaluation of the transition of clinical care for service members with opioid use disorder from the Department of Defense to the Veterans Health Administration. Nicole describes deficiencies in documenting patients’ opioid use disorder, as well as the barriers faced by healthcare providers accessing records, during the transition. 
 

“We want to make sure that all providers are aware of [opioid use disorder] to ensure that this vulnerable veteran population gets the care they need. Even if we prevent one death, this report will have reached the people we really wanted it to.” – Nicole Maxey 

Related Report:  

Review of Clinical Care Transition from the Department of Defense to the Veterans Health Administration for Service Members with Opioid Use Disorder

In this podcast episode of Inside Oversight, Erica Taylor, a health system specialist with the Office of Healthcare Inspections, discusses a healthcare inspection at the West Palm Beach VA Healthcare System in Florida that assessed allegations related to a patient’s cancer care coordination.  

“Over the years, the OIG has published many reports detailing issues related to appointment scheduling with community providers and delays in VA getting clinical information back from community providers. There have been several prior reports that highlight failures in coordinating community care for services.” – Erica Taylor

Related Report: 

Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida

In this episode of Inside Oversight, Amanda Newton, an associate director with the Office of Healthcare Inspections, discusses a report on deficiencies with the Patient Safety Program at the Tuscaloosa VA Medical Center in Alabama. She shares how a lack of resources, supervisory engagement, and failure of facility leaders to act impacted the medical center’s culture of safety. Find this episode at the VA OIG’s podcast page or where you normally listen to podcasts.

“I would just add that this report details deficiencies at just one VA medical center. I think it would serve as a cautionary tale to other facilities throughout VHA. There are lessons learned here that we can certainly apply to other facilities. I really hope that other facilities’ staff and other facilities’ leaders can take the information here and use these lessons to ensure the strength of their patient safety program.” – Amanda Newton

Related Report: 

Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama 

In this episode, Dr. Amber Singh, an associate director with the VA OIG’s mental health team within the Office of Healthcare Inspections, discusses a published report on VHA’s Intimate Partner Violence Assistance Program. Her team conducted a national review of the program to evaluate implementation status and identify perceived barriers to compliance by surveying program coordinators and leaders. She shares how the team found over half of VHA facilities did not have the required program protocol, which may contribute to leader and staff confusion and lack of knowledge about the program’s roles, responsibilities, process, and procedures.

“Fifteen of the 25 coordinators we interviewed described screening as one of the most challenging aspects of IPVAP implementation. They explained to us that screening being optional and lack of staff buy-in due to other priorities in clinical care were barriers to routine screening. Some coordinators suggested screening should be considered.” – Dr. Amber Singh

Related Report: Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance

In this episode of Inside Oversight, Dr. Wanda Hunt, a healthcare systems specialist with the VA OIG’s Office of Healthcare Inspections, discusses a recently published report on VHA’s Intensive Community Mental Health Recovery Programs. Her team examined the visit frequency for veterans enrolled in these programs between April 2019 and March 2021, as well as evaluated VHA healthcare systems’ contingency planning for veteran medication access during emergencies. Dr. Hunt describes how important intensive community mental health recovery programs are to veterans, especially for those with serious mental illness, and how the pandemic impacted patient visits. She shares how her team conducted the review, analyzed the results, and ultimately made three recommendations addressing visit frequency, the ongoing role of virtual care in delivery of these programs, and contingency planning related to medication access during emergencies. 
 

“These types of recovery programs are built on teams having small caseloads and frequent visits in people's communities and homes, and there's good medical evidence showing that this model of care can really improve the lives of people with serious mental illness.” – Dr. Wanda Hunt

Related Report:

Improvements Recommended in Visit Frequency and Contingency Planning for Emergencies in Intensive Community Mental Health Recovery Programs

Related Report: Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois

The VA OIG conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions. 

The OIG substantiated a failure to observe general infection control practices. Residents and staff did not consistently wear face coverings prior to and at times, after the outbreak. Prior to the outbreak, one CLC nursing staff member was fit tested for an N95 mask and no CLC nursing staff had been trained about powered air purifying respirators. Leaders failed to minimize the risk of exposure to COVID-19. Leaders did not respond adequately to a staff exposure, have a plan for the transfer and isolation of residents, implement recommended infection control measures when performing aerosol generating procedures, and continued to hold group therapies. The OIG did not substantiate the facility failed to notify residents, their families, and staff of COVID-19 test results, but did substantiate the lack of a post-baseline testing plan and a failure to test CLC staff after potential exposure. The OIG identified actions taken by leaders following the CLC outbreak lacked input from frontline staff to identify corrective actions and opportunities for improvement.

The OIG made 14 recommendations related to review of the failure to manage an outbreak; mask wearing; respiratory personal protective equipment; adherence to guidance on COVID-19 exposure; operability of the bed management system; policy management; development of comprehensive testing plans; communicating family notification policy; operational risk management; and frontline staff inclusion in facility review.

Related Report:

Failure to Follow a Consult Process Resulting in Undocumented Patient Care at the Chillicothe VA Medical Center in Ohio

The VA OIG conducted a healthcare inspection for 10 allegations related to the quality and management of patient care and the availability of resources within the Urgent Care Center at the Chillicothe VA Medical Center in Ohio.

One allegation involved an urgent care provider sending a patient with a T12 vertebrae compression fracture to have chiropractic care at the Complementary and Alternative Medicine (CAM) clinic. The patient returned a week later with a T12 burst fracture and rib fractures.

The OIG found that an urgent care provider verbally referred a patient for pain management and not for chiropractic care. However, the OIG found that the urgent care provider did not enter a CAM consult until eight days after seeing the patient. Due to this delay, the chiropractor and clinical massage therapist failed to review the consult prior to seeing the patient. Additionally, the chiropractor and massage therapist could not link documentation to the consult and had no other process to complete the documentation resulting in the failure to document care provided within the medical record.

The patient returned to the Urgent Care Center eight days later where a computerized tomography scan showed an acute burst fracture and acute rib fractures. Because of the lack of documentation and provider recall, the OIG could not conclusively determine the relationship between the actions taken by the chiropractor and clinical massage therapist and the patient’s bone fractures.

The OIG found the nine additional allegations to be unsupported and lacked merit.

The OIG made two recommendations to the Facility Director related to education of providers, chiropractors, and clinical massage therapists on the use of consults and timely documentation, and conducting an internal review of the CAM program processes related to patient care, reviewing consults, scheduling appointments, checking-in patients, and documentation.

Related Report:

Care in the Community Healthcare Inspection of VA Midwest Health Care Network (VISN 23)

The OIG Care in the Community healthcare inspection program examines clinical and administrative processes associated with providing quality outpatient healthcare to veterans. This report provides a focused evaluation of Veterans Integrated Service Network (VISN) 23 and its oversight of the quality of care delivered in community-based outpatient clinics (CBOCs) and through its community care referrals to non-VA providers. Although it is difficult to measure the value of well-delivered and coordinated care between VA and non-VA providers, the findings in this report may help VISN leaders identify vulnerable areas of community care that, if properly addressed, should improve healthcare quality for veterans.

The OIG reviewed care coordination for congestive heart failure management; primary care and mental health (diagnostic evaluations following positive screenings for depression or alcohol misuse); quality of care (home dialysis care); and women’s health (mammography care and communication of results).

The OIG issued three recommendations for improvement in two areas:

(1) Quality of Care
• Completing initial and annual home visits for patients accepted into the VISN 23 home dialysis program
• Monitoring quality of home dialysis contracted clinical services

(2) Women’s Health
• Receiving written results from community providers within 30 days of the procedure

Vet Center Inspection Program:
The VA Office of Inspector General Vet Center Inspection Program (VCIP) provides a focused evaluation of aspects of the quality of care delivered at vet centers. Vet centers are community-based clinics that provide a wide range of psychosocial services to clients, including eligible veterans, active duty service members, National Guard members, reservists, and their families, to support a successful transition from military to civilian life. VCIP inspections are one element of the OIG’s oversight to ensure that the nation’s veterans receive high-quality and timely Veterans Health Administration services. The inspection covers key clinical and administrative processes associated with promoting quality care. The OIG selects and evaluates specific areas of focus each year.

Related Reports:

Vet Center Inspection of Pacific District 5 Zone 2 and Selected Vet Centers

Vet Center Inspection of Continental District 4 Zone 1 and Selected Vet Centers

Vet Center Inspection of Southeast District 2 Zone 2 and Selected Vet Centers

Vet Center Inspection of Continental District 4 Zone 2 and Selected Vet Centers

Vet Center Inspection of Pacific District 5 Zone 1 and Selected Vet Centers

Related Report: Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight

Report Summary: 
As part of the Veterans Health Administration’s (VHA) suicide prevention strategy, suicide prevention coordinators at VA medical facilities are required to reach out to veterans referred from the Veterans Crisis Line. Coordinators provide access to assessment, intervention, and effective care; encourage veterans to seek care, benefits, or services with the VA system or in the community; and follow up to connect veterans with appropriate care and services after the call. VHA’s Office of Mental Health and Suicide Prevention is responsible for issuing policy and guidance for managing crisis line referrals. The VA Office of Inspector General (OIG) conducted this review to evaluate whether coordinators properly managed crisis line referrals to ensure at-risk veterans were reached.

The OIG found that coordinators mistakenly closed some veteran referrals because coordinators lacked the proper training, guidance, and oversight necessary to maximize chances of reaching at-risk veterans referred by the crisis line. VHA lacked comprehensive performance metrics to assess coordinators’ management of crisis line referrals, and coordinators lacked clear guidance on how to manage crisis line referrals. Until VHA provides appropriate training, issues adequate guidance, and improves performance metrics, coordinators could miss opportunities to reach and assist at-risk veterans.

The OIG made five recommendations to the under secretary for health that include improving data integrity, training coordinators on using patient outcome codes, developing additional guidance, monitoring compliance with requirements to space calls over three days, and evaluating program data for additional opportunities to improve services for referred veterans.