Veteran Oversight Now

In this latest episode of Veteran Oversight Now, we’re revisiting a highly downloaded episode from February 2024—Unpaid Postage Bill Delays Critical Cancer Screenings. Hear from a VA OIG healthcare inspection hotline director, who discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from September 2024. “The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

In this latest episode of Veteran Oversight Now, we’re revisiting a highly downloaded episode from April 2024—Veteran Dies Following Delay in “Code Blue” Alert at Memphis VA Medical Center.  Hear from a VA OIG healthcare inspection hotline director discuss how a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition also includes highlights of the VA OIG’s work from August 2024.       “Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses findings at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, where there was no documentation of required reusable medical device reprocessing, which put patients at risk for infection if the reusable medical devices used during subsequent procedures were, in fact, not cleaned per requirements. The VA OIG also found that high-level disinfection documentation was missing and made seven recommendations related to oversight of the medical center’s Sterile Processing Service. This episode also includes highlights of the VA OIG’s work from July 2024.         “If it’s [medical device] not documented properly and it’s not documented in the system so that we can track the cleaning, the disinfecting, the sterilization, then we don’t know if it’s processed appropriately.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VAMC in Albuquerque, New Mexico

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses allegations that facility staff at the VA Southern Nevada Healthcare System in Las Vegas delayed ordering medications following an elderly patient’s discharge from a community hospital. The OIG substantiated that inadequate care coordination led to a delay in ordering discharge medications and found deficiencies in facility staff's response to the patient’s death by suicide.  “If you go by the timeline, this is 17 days after the patient’s first visit to the emergency room with the shortness of breath problems. . . . Unfortunately, the patient completed suicide that same day without receiving the medication.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director This podcast edition also includes highlights of the VA OIG’s work from June 2024.   Related Report:  Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses allegations that some patients’ behavioral health consults were being discontinued at the Oklahoma City VA Medical Center, which resulted in some significant delays in patients receiving recommended behavioral health services. This podcast edition also includes highlights of the VA OIG’s work from May 2024.       “Both in the allegation and what we found was basically that the program manager lacked a working knowledge of the consult management and scheduling processes.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma

In the latest episode of Veteran Oversight Now, VA Inspector General Michael J. Missal discusses the VA OIG’s latest Semiannual Report to Congress that covered our oversight work from October 1, 2023, to March 31, 2024. Specifically, he shares results of our most recent work related to VA’s Electronic Health Record Modernization program. To date, the VA OIG has published 19 products addressing the program’s implementation across VA facilities nationwide. In addition, IG Missal shares his thoughts on the VA OIG’s work related to VA’s personnel suitability program as well as recent crime and fraud alerts. A recent fraud alert encourages VBA staff to report when veterans share that they are being charged high fees from unaccredited individuals for assistance with completing disability benefits questionnaires (DBQs) or an initial claim filing. This podcast edition also includes highlights of the VA OIG’s work from April 2024.       “It's wonderful to be able to talk about all the incredible work that our staff performs in the service of our nation's veterans. I could not be more proud of the progress our staff has made in achieving our mission to serve veterans and the public by conducting meaningful, fair, and evidence-driven oversight of VA.” – Inspector General Michael J. Missal.Related Report: 91st Semiannual Report to Congress

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses a telemetry technician’s failure to follow a series of communications within the time frame established in the facility’s cardiac telemetry monitoring policy delayed initiating a code blue alert, ending with the patient’s death. This edition also includes highlights of the VA OIG’s work from March 2024.       “Once the patient's heart rate completely stopped and they went into asystole, that should have triggered a code blue. Period.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how multiple OIG reports detail chronic leadership failures at the Indianapolis, Indiana VA medical center. This edition also includes highlights of the VA OIG’s work from February 2024.       “It overall affects the care that the patients receive. Some of the care just wasn’t available anymore because they didn’t have the cardiologists available.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses delays in the receipt of patients’ colorectal cancer screening tests due to an unpaid postage bill by the Phoenix VA Health Care System in Arizona. This edition also includes highlights of the VA OIG’s work from January 2024.       “The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related Report: Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona

In the latest episode of Veteran Oversight Now, VA Inspector General Michael J. Missal shares his thoughts on changes to federal oversight since the passage of the Inspector General Act in 1978, which established 12 presidentially appointed IGs in federal departments with a mission to provide independent oversight. The VA OIG was one of the original 12. He also discusses the VA OIG’s latest Semiannual Report to Congress that covered oversight work from April 1 to September 30, 2023. This edition also includes highlights of the VA OIG’s work from October 2023.       “As only the sixth Senate-confirmed VA Inspector General over the past 45 years, it is truly an honor and privilege to work on behalf of veterans and taxpayers. It is also a real honor and privilege to work with all of our staff to meet our mission of meaningful independent oversight. We had a great fiscal year 2023 and we look forward to an even more impactful fiscal year 2024.” – VA Inspector General Michael J. Missal Related Reports: VA’s Compliance with the VA Transparency & Trust Act of 2021 Semiannual Report: September 2023Manufacturers Failed to Make Some Drugs Available to Government Agencies at a Discount as RequiredReview of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 PandemicRead the VA OIG's 90th Semiannual Report to Congress.

In this latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses the lessons learned in the care of a veteran who died after a fall in a VA outpatient clinic, part of the Southern Nevada Healthcare System in Las Vegas. This edition also includes highlights of the VA OIG’s work from August 2023.       “Since [the incident] happened, the facility has made several adjustments to ensure that in an emergency situation that staff is knowledgeable of the processes that they need to implement and carry out that will hopefully result in a better outcome.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline DirectorRelated Report: Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las VegasPublished: 6/28/2023Report #22-02725-132

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses deficiencies in the quality of emergency department care for a veteran who died by suicide at the John Cochran Division of the VA St. Louis Healthcare System in Missouri. This edition also includes highlights of the VA OIG’s work from July 2023.“Approximately 10 minutes later is when the staff person finds the patient unresponsive in the exam room with a ligature around his neck. A code was called, meaning a code blue so that all emergency staff would present to that room, and they tried to resuscitate the patient, but that was unsuccessful, and he was pronounced dead about 10 to 15 minutes later.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director Related ReportDeficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses missteps in the care of a veteran who eventually committed suicide on the grounds of the Aiken Community Based Outpatient Clinic, part of the Charlie Norwood VA Medical Center in Augusta, Georgia. This edition also includes highlights of the VA OIG’s work from June 2023.       “In VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider.” – Trina Rollins, VA Office of Inspector General, Office of Healthcare Inspections, Hotline Director  Related Report:Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia

In the latest episode of Veteran Oversight Now, a VA OIG healthcare inspection hotline director discusses how she and her team triage healthcare-related hotline inquiries. She shares how concerns over the management of a patient safety program led to an inspection and subsequent report at the Tuscaloosa VA Medical Center in Alabama. This edition also includes highlights of the VA OIG’s work from May 2023.       “I think the takeaway for all of this is VHA needs to ensure involvement of all staff in the patient safety program at the respective facilities, but also ensure oversight of those safety patient safety programs. The oversight is just as important as participation when trying to ensure that the facility has opportunities to identify system vulnerabilities and then address those concerns with the hopes of preventing future patient safety events from occurring.” Trina Rollins, Director of Hotline Coordination, Office of Healthcare InspectionsRelated Publications:Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in AlabamaComprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama (September 2, 2020)Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama (September 27, 2019)

IG Michael J. Missal discusses the VA OIG's 89th Semiannual Report to Congress covering the reporting period of October 1, 2022, to March 31, 2023. Plus oversight highlights from the VA OIG's work in March and April of 2023. For this six-month period, the VA OIG identified more than $401 million in monetary impact for a return on investment of $4 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. During this six-month period, the Office of Investigations opened 222 cases and closed 217 (most of which were opened in prior periods), with efforts leading to 122 arrests. The OIG hotline received and triaged 15,526 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 595 administrative sanctions and actions. The Office of Audits and Evaluations (OAE) produced 52 work products, including one VA management advisory memorandum that highlighted concerns requiring VA’s prompt attention, 19 oversight reports, and 32 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 128 recommendations. The Office of Special Reviews issued two publications, including an administrative investigation that focused on VHA employing four people who had been previously excluded from holding a paid position in a federal healthcare program. The Office of Healthcare Inspections (OHI) focused on leadership and organizational risks, suicide risk reduction, and care coordination. OHI published 14 healthcare inspection reports; two national healthcare reviews; 11 Comprehensive Healthcare Inspection Program (CHIP) reports, including four CHIP summary reports; two Vet Center Inspection Program reports; and two Care in the Community reports.   Featured Publications:Stronger Controls Help Ensure People Barred from Paid Federal Healthcare Jobs Do Not Work for VHAVeterans Are Still Being Required to Attend Unwarranted Medical Reexaminations for Disability BenefitsDeficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by FirearmsOpioid Safety at the VA Northern California Health Care System in Mather

In this episode, host Fred Baker talks with Dr. Julie Kroviak, the principal deputy assistant inspector general of the VA OIG’s Office of Healthcare Inspections, about changes to how cyclical healthcare reviews are conducted. Dr. Kroviak explains how her teams are reworking the Comprehensive Healthcare Inspection Program cyclical reports to provide more information on the veteran communities being served by VA medical facilities. Additionally, she shares how, for the first time, the VA OIG will start reviewing VA mental health programs cyclically.             “We're going to start with a glimpse of the community that the facility operates in, and that's totally new. We've never done anything like that but giving the reader a sense of who's living in this community, what's the education level, what's the income level, the disease burden, active duty and veteran populations, all of these [factors] sort of really influence how care is delivered, and we want to present that in a reader-friendly kind of glimpse so you can understand what's influencing care and the veterans served in that community.” – Dr. Julie Kroviak

In this episode of Veteran Oversight Now, host Fred Baker talks with Shawn Steele, the director of the VA OIG’s Office of Audits and Evaluations Healthcare Infrastructure Division. Taking a very unique approach, 150 OIG staff recently mobilized to evaluate the security posture of 70 VA medical facilities over three days. Persistent police staffing shortages and growing concerns about incidents that put VA staff, patients, and visitors at risk led the OIG to conduct the review, Security and Incident Preparedness at VA Medical Facilities. OIG teams assessed whether each VA medical facility visited had established a minimum-security posture and had taken required actions according to VA policy. The OIG identified multiple security vulnerabilities and deficiencies, most notably staffing shortages that contributed to the lack of a visible and active police presence.  “VA medical facilities are meant to be welcoming. They’re meant to be easy to access and as a result have many entrances. On top of that, there are 171 geographically diverse medical facilities in the VA network, and each of them come with their own unique challenges. It’s important to understand that there is not one [security] template that can be applied. There are 171 templates that need to be applied.” – Shawn Steele Related Report:Security and Incident Preparedness at VA Medical Facilities

In this episode of Veteran Oversight Now, host Fred Baker chats with Dr. Beth Winter, a psychiatrist with the VA OIG’s Office of Healthcare Inspections. They discuss her path from wanting to provide care for exotic animals to choosing to be “a people doctor instead of an animal doctor.” Dr. Winter’s distinguished career eventually led the granddaughter and daughter of veterans to the VA OIG helping provide oversight of VHA’s health care system. In this podcast, Dr. Winter discusses her work related to the prevention of veteran suicide by lethal means in the recently released report Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms. She explains that the time between a veteran deciding to act and actually attempting suicide can be just five or 10 minutes and relatively simple interventions during that period can be critical in preventing suicide. This month’s episode concludes with a summary of the VA OIG’s oversight highlights for December 2022. “That window is really between the decision to act and the action itself and … we also know that if there was some barrier to accessing a person’s initial method for suicide—for example a gun lock, or a gun being placed in a safe, or a gun being separated from ammunition within the house—that gives people time to either reconsider their action, or they might make the attempt with a method that’s significantly less lethal. So, if we can increase that window between the decision to act and the action itself, we significantly increase the possibility of that person’s survival.” – Dr. Beth Winter Related Report:Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms

The Semiannual Report to Congress summarizes the VA Office of Inspector General’s (OIG) oversight efforts from April 1 through September 30, 2022. For this six-month period, the VA OIG identified more than $1.4 billion in monetary impact for a return on investment of $16 for every dollar spent on oversight—which brings the fiscal year 2022 totals to nearly $4.6 billion in monetary impact for a return on investment of $24 for every dollar spent on oversight. These figures do not include the inestimable value of the healthcare oversight work completed to advance patient safety and quality care. During this six-month period, the Office of Investigations opened 178 cases and closed 213 (most of which were opened in prior periods), with efforts leading to 135 arrests. The OIG hotline received and triaged 18,396 contacts to help identify wrongdoing and address concerns with VA activities. Collectively, the work during this period resulted in 599 administrative sanctions and actions. The Office of Audits and Evaluations (OAE) produced 44 publications, including five VA management advisory memorandums that highlighted concerns requiring VA’s prompt attention. Contracting review teams also conducted 47 preaward and postaward contract reviews to help VA obtain fair and reasonable pricing on products and services. OAE reports for the six-month period resulted in 198 recommendations. The Office of Special Reviews (OSR) issued five publications, including three reports in response to allegations of senior VA officials’ misconduct, which reflect the VA OIG’s commitment to holding VA employees accountable for wrongdoing and promoting the highest standards of professional and ethical conduct. OSR also issued two joint publications: a VA management advisory memorandum with OAE regarding concerns with the calculation of patient wait time data, and a report with the Department of Defense (DoD) OIG, focusing on efforts by DoD and VA to achieve electronic health record system interoperability. The Office of Healthcare Inspections (OHI) maintained a strong focus on leadership and organizational risks, suicide risk reduction, quality of care, and patient safety. OHI published 19 healthcare inspection reports; 17 Comprehensive Healthcare Inspection Program (CHIP) reports, including three CHIP summary reports; four national healthcare reviews; and its first Care in the Community report that examined key clinical and administrative processes associated with providing quality VA and community care.

Mentioned Investigations: Former VA Hospital Nursing Assistant Sentenced to Seven Consecutive Life Sentences for Murdering Seven Veterans and Assault with Intent to Commit Murder of an Eighth Fayetteville Doctor Sentenced To 20 Years In Federal Prison For Mail Fraud And Involuntary Manslaughter Retail Ready Owner to Forfeit $72M for VA Tuition Fraud