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 TaylorRelated 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 NewtonRelated 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 SinghRelated 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 HuntRelated 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, IllinoisThe 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 OhioThe 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 CentersVet Center Inspection of Continental District 4 Zone 1 and Selected Vet CentersVet Center Inspection of Southeast District 2 Zone 2 and Selected Vet CentersVet Center Inspection of Continental District 4 Zone 2 and Selected Vet CentersVet Center Inspection of Pacific District 5 Zone 1 and Selected Vet Centers

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

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide at the Harry S Truman Memorial Veterans’ Hospital in Columbia, Missouri The VA OIG conducted a healthcare inspection to determine the validity of an allegation regarding a patient’s mental health care at the Harry S. Truman Memorial Veterans’ Hospital (facility) in Columbia, Missouri, prior to death by suicide. The OIG reviewed the patient’s mental health care coordination, discharge planning, suicide risk screening and evaluation, administrative actions, and Mental Health Treatment Coordinator (MHTC) assignment. The OIG substantiated that the patient died by suicide within three days of discharge from the facility’s Inpatient Mental Health Unit. The OIG also substantiated that an inpatient psychiatry resident initiated antidepressant medication, and a registered nurse provided discharge instructions that included suicide prevention materials, consistent with Veterans Health Administration (VHA) guidance. Inpatient staff did not include Columbia Vet Center staff in discharge planning and failed to complete the VHA-required comprehensive suicide risk evaluation prior to the patient’s discharge, which may have contributed to missed information to adequately establish acute and chronic suicide risk factors and a risk mitigation plan. Facility leaders did not establish an MHTC policy and staff did not assign the patient’s MHTC while awaiting transfer to another level of care. Staff failed to comprehensively report a positive suicide risk screening result in an issue brief related to the patient’s death, and facility leaders, in part based on the issue brief, did not make an institutional disclosure to the patient’s next of kin. Veterans Integrated Service Network and National Center for Patient Safety leaders did not have knowledge of a memorandum of understanding that required Vet Center representation for shared patients during VHA root cause analyses. The OIG made one recommendation to the Under Secretary for Health and six recommendations to the Facility Director.

Challenges for Military Sexual Trauma Coordinators and Culture of Safety ConsiderationsThe VA OIG conducted a review of select activities and challenges of Military Sexual Trauma (MST) Coordinators and Veterans Integrated Service Network Points of Contact in response to a request from Congressman Chris Pappas, Chairman of the House Veterans’ Affairs’ Subcommittee on Oversight and Investigations, and Congresswoman Julia Brownley, Chairwoman of the Women Veterans Task Force. The OIG also reviewed the culture of safety for patients requesting MST-related care. Sexual trauma experienced while serving in the military affects both women and men with potentially serious and long-term consequences. Psychological trauma, such as MST, also increases risk of physical health conditions such as cardiovascular disease, stroke, and diabetes. The Veterans Health Administration requires that each facility has a designated MST Coordinator with at least 20 percent of their time dedicated to protected administrative time. The OIG conducted a national survey and interviews to evaluate MST Coordinators duties and perceived challenges. Approximately 80 percent of the respondents reported having been assigned at least 20 percent or more of protected time. Thirty-nine percent reported inadequate resources to fulfill MST Coordinator administrative responsibilities. Based on analysis of survey results and interview information, the OIG found that insufficient protected administrative time, role demands, insufficient support staff, and inadequate funding and outreach materials challenged MST Coordinators’ ability to fulfill role responsibilities. Additionally, the OIG found that MST Coordinators who reported more dedicated time than other MST Coordinators did not necessarily serve at facilities with higher numbers of patients in MST related care.The OIG made one recommendation to the Under Secretary for Health to evaluate the sufficiency of current guidance and operational status regarding protected administrative time, administrative staff support, and funding for outreach, education, and special project resources, with consideration of MST Coordinators’ responsibilities, and take action as warranted.

Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 PandemicThe VA Office of Inspector General (OIG) conducted a review to assess Veterans Health Administration’s (VHA) virtual primary care response to the COVID-19 pandemic, as well as the use of virtual care by primary care providers and their perceptions of VA Video Connect (VVC) between February 7 and June 16, 2020. The COVID-19 pandemic presented significant challenges to health care delivery worldwide. One strategy initiated by VHA, in accordance with the Centers for Disease Control and Prevention recommendation to social distance, included expanding the delivery of primary care via virtual care. In VHA, virtual care has had a long-standing presence as a modality of care. Virtual care options during the pandemic included video conferencing through VVC and third-party applications, such as Skype and FaceTime, as well as telephone appointments. The OIG found face-to-face primary care encounters decreased by 75 percent and virtual encounters increased, with contact by telephone representing 81 percent of all primary care encounters during the review period. Additionally, primary care providers reported via questionnaire that VVC training and support were lacking for veterans, as was technology equipment and internet connectivity. Providers also identified challenging scheduling processes related to virtual appointment scheduling as a concern. The OIG made two recommendations to the Under Secretary for Health related to access, equipment, and VVC application training and support.

Senior Auditors Geoff Ferguson and Gris Soto discuss two related reports on improper payments for community acupuncture and chiropractic services and overall risks to evaluation and management services. In the first report, the VA OIG audited acupuncture and chiropractic care by non‑VA providers after becoming aware of patterns that suggested questionable billing practices by those providers. In the second report, the VA OIG conducted a review to identify and evaluate the VHA’s risk of improperly paying community care providers for evaluation and management services not supported by medical documentation. Both reports were published on December 8, 2021. Referenced reports: VHA Improperly Paid and Reauthorized Non-VA Acupuncture and Chiropractic ServicesThe Office of Community Care, part of the Veterans Health Administration (VHA), manages programs that allow veterans to receive medical care from non VA providers. This audit evaluated whether VHA paid for non-VA acupuncture and chiropractic care that was not authorized or supported by medical documentation. The audit team also assessed whether VHA followed guidance for reauthorizing the care. The team found that VHA paid for care that was not authorized, including for more visits than allowed and for treatments not allowed by standards for care. For example, some acupuncturists billed for more than two rounds of needle insertions when only two rounds were allowed. VA’s automated system for processing claims did not prohibit unauthorized visits or unallowable treatments in claims submitted by non-VA providers. Further, VHA paid acupuncture and chiropractic claims that lacked appropriate supporting medical documentation. The unsupported payments persisted because VHA staff did not retroactively review documentation samples for deficiencies. The audit team estimated that improper payments for acupuncture and chiropractic care amounted to about $136.7 million during fiscal years 2018 and 2019. The audit team also found that VHA did not always follow guidance when reauthorizing acupuncture and chiropractic care. Not documenting assessments of prior treatments before authorizing additional care may interfere with veterans’ treatment. The OIG made six recommendations to the under secretary for health related to adding automated payment system controls, auditing the payment process, retrospectively auditing non-VA medical documentation, making continuing education material related to medical documentation available to non-VA providers, following the Office of Community Care’s Field Guidebook, and documenting clinical justification for non-VA care. VHA Risks Overpaying Community Care Providers for Evaluation and Management ServicesThe OIG conducted this review to determine the risk of the Veterans Health Administration (VHA) improperly paying community care providers for evaluation and management services not supported by medical documentation. The review team found that some providers are billing VA at a significantly higher rate for high-level evaluation and management services than their peers in the same specialty. The team determined that in fiscal year (FY) 2020, more than 37,900 non-VA providers billed and were paid for significantly more high-level evaluation and management codes than were all providers in that specialty on average. These non-VA providers received about $39.1 million (13 percent) of the approximately $303.6 million paid for all non-VA evaluation and management services. Additionally, some providers billed separately for evaluation and management services during periods when the global surgery package was in effect. This package is supposed to cover all surgery-related services for a set period. The review team identified more than 45,600 providers who were paid about $37.8 million in FY 2020 for these evaluation and management services. Improper payments were not easy to detect because VHA staff did not retrospectively audit medical documentation as required. Additionally, the OIG found no evidence that VHA or contractors trained non VA providers on documenting evaluation and management services, similar to how VA providers are trained. The OIG determined VHA risked overpaying for evaluation and management services by about $19.9 million in FY 2020. The OIG made two recommendations to the under secretary for health related to (1) reviewing medical documentation for evaluation and management services billed by non-VA providers and then developing processes to act on the results of those reviews; and (2) ensuring non-VA providers receive current and future continuing education materials on proper medical documentation for evaluation and management services.

In this episode of Inside Oversight, Daniel Morris, a director within the Office of Audits and Evaluations, provides insight into a recent VA OIG management advisory memo that reported on concerns with consistency and transparency in the calculation and disclosure of VHA’s patient wait times. Report Summary: Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time DataIn June 2021, a complainant alleged that the then acting principal deputy under secretary for health had been informed in the fall of 2019 that VHA’s patient wait times reporting may be misleading but that no action was taken in response. After an initial examination, the OIG determined that there was no basis to proceed with a misconduct investigation of the then acting principal deputy under secretary for health, as the OIG found no evidence of intent or efforts to mislead. This management advisory memo, however, details how VHA has presented wait times to the public without clearly and consistently disclosing the basis for their calculations. Since 2014, VHA has employed several different methodologies (particularly using different start dates) for calculating wait times reported online, as well as for determining whether wait time criteria are met for community care program eligibility. The methodologies deviated in some instances from VHA’s scheduling directive and its stated wait time measures announced in the Federal Register in 2014. As a result, VHA has presented wait times with different methodologies, using inconsistent start dates that affect the overall calculations without clearly and accurately presenting that information to the public. The OIG found that efforts to improve wait time disclosures had been under consideration but had been deferred by urgent priorities, including the COVID-19 pandemic. VHA’s efforts to improve the accuracy in its reporting of the timeliness of veterans’ access to care are dependent on the consistency of its calculations of wait times and its transparency regarding which methodologies and data sources have been used, together with any limitations. This memo serves to alert VA of the problems identified regarding wait time calculations and reporting, and requests that VA inform the OIG what action is taken to address the identified issues.