Veteran Oversight Now

Fred Baker: Welcome back to another episode of Veteran Oversight Now, an official podcast of the VA Office of Inspector General. I'm your host, Fred Baker.

Each month on this podcast, we'll bring you highlights of the OIG's recent oversight activities and interview key stakeholders in the office’s critical work for veterans.

This is a special hotline edition of Veteran Oversight Now and joining us today is Trina Rollins. Trina is the director for hotline coordination within the VA OIG's Office of Healthcare Inspections. Trina is a board-certified physician assistant who worked at the VA North Texas healthcare system for eight years prior to joining the VA OIG in 2011. Welcome, Trina.

Trina Rollins: Thanks, Fred. I'm glad to be here.

Fred Baker: Well, Trina, today we have another very difficult report to have a conversation about that ultimately led to a very tragic event. Before we get into the report and its details tell me a little bit about where we're conducting this inspection and what that facility looks like.

Trina Rollins: So, the inspection was actually at the John Cochran division of the VA St. Louis Healthcare System, and if you're not familiar with that healthcare system there are actually two divisions. So, John Cochran and Jefferson Barracks, this is a level 1A complexity so that is the most complex facility type in the VA system, and it is a full-service inpatient medicine and surgical services along with outpatient psychiatric care and over 65 other sub-specialties. These two divisions, this healthcare system is part of VISN 15. And this is the highest-level complexity type facility that VA has.

Fred Baker: And explain a little bit about how this referral came to your desk.

Trina Rollins: Sure, so with all referrals to OIG, it comes in through our hotline division, and then they decide which directorate within OIG is the best to review it. This being a healthcare issue, a suicide, it came to our division and when we initially reviewed it, we decided to first ask the facility to respond to the allegations, and what that entails is giving them about 60 days to look at the allegations. Do any type of review that they do internally and then provide us a written response. When we got that written response, we were not satisfied. Honestly, it left us with more questions than answers, so that's when we decided we needed to open up a hotline inspection and go on site and do these interviews that we normally do to do these types of evaluations and get the information ourselves.

Fred Baker: So that's one thing before we get into details, I want to talk about just a little bit is given the very tragic events, how hard is it to go in and extract these details from individuals who may or may not want to discuss the events of the day?

Trina Rollins: It's very difficult, but you know, in this case we know the outcome, I mean the facility staff were right there, they saw the result. You know, a nurse triaged this patient, brought him into the emergency department room to be evaluated by a physician, and then two and a half hours later, a staff person found this patient unresponsive in the room and who was later declared deceased.

Fred Baker: As we talked about earlier this is a very, very tragic report, very, very sad ending. Certainly, many missteps, many learning points, and we'll go through discussing those. As we mentioned, this report does focus on a veteran who showed up at an emergency department in early fall of 2021 very early in the morning, little after 5 a.m., complaining of urinary retention and depression. Go ahead and characterize with for me if you will kind of the initial events of this engagement there at the emergency department.

Trina Rollins: Sure, I'm going to give you a little bit of background on the patient too, because I think it's important as the events unfold again this veteran is a male. He had a history of prostate issues. He also had a history of depression, post-traumatic stress disorder, substance abuse, and chronic pain from spinal stenosis. This patient, this veteran, had been hospitalized multiple times from 2001 to 2020. For suicidal thoughts and substance abuse, he had previously had suicide attempts, so again, this is all of his history. He shows up that morning in the fall, as you said early in the morning, around 5:14 a.m., presents to the emergency department saying that he's having difficulty with his urination and that he's depressed. He's feeling down and he says he doesn't want to die. This is the conversation he had with the nurse that triaged him. Triaging in the emergency room setting means that they take in the list of symptoms, and then they, the nurse, will decide on a level between one and five of the severity of the symptoms, and then that determines how urgent the situation is for the patient to be seen.

Fred Baker: Just for clarity, this patient was not going to a facility he'd never been before. So, all of these events should have been in his record, and they should have set off various flags with respect to his, how to move forward with this care.

Trina Rollins: Correct. I mean to be fair; the triage nurse usually is the first person that the patient sees when they come into the emergency department. That nurse may not have the time to go through the chart and get all of this information, but as you know, as you're taking in this information, you would at least look at the problem list in the medical record. And what that problem list would show in this case is this patient has had suicidal ideation in the past, has had hospitalizations for suicide attempts, has PTSD, has depression, has substance abuse again, which are all risks for suicide.

Fred Baker: So, one of the first missteps as, as I read the report, happened at this point, right off the start, with her suicide risk screening.

Trina Rollins: Correct. You know, when a patient comes in having a complaint of depression and again, this this gentleman actually said ‘I don't want to die’ to this nurse as she performed or is supposed to perform or a suicide risk assessment. And what that is, it's a set of questions that will then help to evaluate the risk of suicide and the urgency in which this patient needs to be evaluated for those types of symptoms. This nurse, we believe, did the screening by memory, meaning that they asked the questions by memory. You know these types of screening tools are developed and studied by researchers, and they're asked a certain way and they are worded in a certain way to prevent bias from creeping in. So again, you know, when you ask a question, you can ask it in more than one way and the way you ask it can infer some bias to it. So that's why they want you to when using the screening tool, read the questions verbatim, and then wait for the response from the veteran or the patient.

Fred Baker: So, the nurse did not do that. And if I remember in the report, they said they did them from memory, but then in the investigation they could not recall the exact questions by memory.

Trina Rollins: Correct and so again, you know, it just makes us question whether or not the questionnaire, the evaluation is appropriately delivered and then you know the assessment that was received the question the way the veteran answered the questions, did it result in the right type of assessment and evaluation of the patient.

Fred Baker: And this patient was assigned an emergency severity index Level 3. Can you explain that?

Trina Rollins: So again, I kind of mentioned that this emergency severity index is the scale from one to five, one being the most urgent meaning you know a heart attack, a stroke. Those you know, a severe trauma situation. Those patients need to be seen immediately because there's some type of immediate life-saving intervention that's needed. A Level 3 is the least urgent, so those patients could wait in the waiting room. Sometimes though those types of patients could be referred back to their primary care provider. Or to an urgent care center type setting instead of the emergency department. A Level 3 patient is considered stable. There's no acute risk or immediate threat to life.

Fred Baker: So, at this point, Level 3 you said was considered stable and they moved the patient to the exam room.

Trina Rollins: They actually did. So, they moved the patient to an exam room, which, you know, for a Level 3, they don't necessarily have to go back immediately. But again, this was very early in the morning. The emergency department wasn't that busy. They moved the patient to an exam room and did what's called a post void residual. Meaning, they asked the patient to try and urinate, and then they ultrasound his bladder in order to determine how much residual urine was left in there and that was pretty much done immediately and then that nurse documents that they alerted the emergency room physician that the patient was in the room waiting to be seen. Unfortunately, no one can prove that. The video surveillance in the emergency department does not show that the nurse went to where the physician was located and made any type of effort to alert the physician who was actually resting, sleeping at the time you know, to alert the physician that the patient was actually present.

Fred Baker: And to be clear on that, the physician, was allowed to be sleeping on that shift if they weren't doing anything?

Trina Rollins: Correct. This is a night shift when you know when things do slow down, it's not uncommon for an emergency department provider to take a nap just to refresh themselves before the next wave of patients come in.

Fred Baker: So, at 5:30 a.m., nurse one, the first nurse documented that the emergency department physician was notified. And you say that there was no evidence that notification happened. So, what happens after what?

Trina Rollins: Correct, there was no video. There was no video evidence that actually happened.

Fred Baker: What happened after that?

Trina Rollins: So, there is a big gap in time, 45 minutes, and then a second patient comes into the emergency department, a different nurse triages that patient and then that nurse is the one that goes back to the physician and says two patients are waiting to be seen. That's around 6:14 in the morning. So, an hour after our patient presented to the emergency department. Now understand the second nurse did not go in and see the patient, the original patient, she just told the physician that now there's two patients waiting to be seen.

Fred Baker: So, then it's 7:30 and the original, the first nurse was changing shifts, provided an incoming day shift emergency nurse with the status. So, from 5:14 until 7:30 a.m., no one has seen physically this patient.

Trina Rollins: No one has gone back. No one has gone back to see this patient during that time frame.

Fred Baker: So, I don't want to get too far ahead of our findings, however, I want to bring up the door to dock policy. So, explain that and then put that in context with how long this patient has been there without being seen.

Trina Rollins: So VHA has their own emergency department metric, meaning they would like patients to be seen timely. So, their own metric of wait time is from the arrival to the emergency room to being seen by a physician is 25 minutes or less, so that's their own internal metric, internal requirement. You know, sometimes that can be met, you know, in this case, it should have been met because the emergency room only had two patients or one patient at the time our patient presented, but you know at other times the emergency room may be slammed and it may not be met because of the amount of patients being seen or you know coming into the emergency room at that time. But the expectation is 25 minutes or less that a patient presents to the emergency department and then is seen or evaluated by a provider.

Fred Baker: And as of the shift change, at 7:30, it's been more than two hours. And the patient hadn't been seen. And I want to bring up one other note that's important to the timeline. Given the patient’s history of suicide attempts and suicidal thoughts should someone have been checking on him?

Trina Rollins: Yes. When patients come to the emergency room, there's some urgency to their problems, this patient was triaged to Level 3, so he had some urgent need. And yet no one went in to see him. No one took vital signs. You know the expectation should have been at least hourly rounding and this was told to OIG from nursing leadership that the expectation is that patient should be checked on at least every hour. There was no written policy of that, but the expectation was there. You know this patient at the very least the Emergency Severity Index Tool states that a Level 3 patient should have vital signs every two hours. So, by 7:30 that two-hour time frame had already passed and still no one had gone in to take another set of vital signs on him. With, you know, with his history and with his presenting complaint of depression and not wanting to die, yeah, someone should have gone in and at least laid eyes on him. If they didn't do another set of vitals just to check and make sure he was OK, if he was having other symptoms, if he was having pain, if you know any of the symptoms had worsened.

Fred Baker: And so, at 7:30, there's a shift change, and unfortunately tragic events unfold following kind of give us the timeline of what happens next.

Trina Rollins: Well, yeah, unfortunately, it's even a little worse than that. So, let's back up 6:45–6:50, the emergency department chief arrives because the chief is scheduled to work the next shift. He notices there's two patients on the board to be seen that haven't been seen, so he goes and talks to the physician and says you need to see these patients. Shift change occurs at 7:30. The first nurse hands over the patient to the incoming shift, the physician finally, gets up out of his resting area and goes into the room where the patient is located. And can't find the patient. So, he asked another emergency department staff person to go and try and find the patient. Approximately 10 minutes later is when that 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 you know, about 10-15 minutes later.

Fred Baker: So, to be clear, when the physician said he couldn't find him, the patient didn't leave the initial exam room.

Trina Rollins: He did not. He was located between the wall and the bed. So, if you're looking into an exam room and you're just looking at the bed or a chair expecting to see the patient, which I'm assuming is what the physician did, he didn't see the patient. He didn't go into the room and look around. It was the actual emergency department tech or staff person that went in and actually found the patient in a kneeling position between the bed and the wall with the ligature around his around his neck.

Fred Baker: And so, sadly, a medical examiner conducted an autopsy and confirmed that this patient died by suicide as a result of hanging himself with a cord that was there in the exam room.

Trina Rollins: Exactly. And again, the cord is of the medical equipment that's in the room. So, if you've ever been in an exam room for your doctor or the emergency department, you know the tools they use to look into your eyes and ears are connected to usually a box on the wall and it does have a cord attached to it because they're reusable and that is what this patient used to harm himself.

Fred Baker: So, we identified three primary areas of deficiencies.

Trina Rollins: Correct the administration of the suicide risk assessment screening the...

Fred Baker: Meaning nurse, the nurse did it incorrectly.

Trina Rollins: The physician didn't evaluate the patient; you know two and a half hours later he was found dead.

Fred Baker: First, he wasn't, we don't believe he was notified. And then even after he was notified, he delayed providing care.

Trina Rollins: And again, realize we don't know exactly when this patient killed himself. So, we don't know if he if the physician had responded at 6:14 a.m. when the second nurse had alerted him of the patients being waiting to be seen if that could have prevented this from happening. And then again, the door to dock metric for VHA is 25 minutes and this was two and half hours later.

Fred Baker: Sure. Exactly when.

Fred Baker: And then finally, the failure to monitor the patient.

Trina Rollins: Failure to monitor the patient, yes.

Fred Baker: And tell me what that looks like when a patient has a history of suicide you had mentioned that they would, they wouldn't necessarily station someone outside the door, but they would put that patient within a line of sight.

Trina Rollins: Exactly, if you, if you look at the report, there's a little drawing of the emergency department and so, the physician was in one room, there was an empty room next to that and then the patient was placed in the third room. The third room had no line of sight to the nurses’ station so if nursing staff were sitting at the nurses' station working on their computers charting, they would not be able to see into that patient room to monitor that patient. So, the only other alternative at that time of the day would have been to actually station someone outside the room, something that would have been, in my opinion more appropriate would be to place the patient in the room that was directly across from the nurses’ station. So again, you've got line of sight, meaning you could see the patient in the room, but you don't necessarily have to have someone stationed in the room or directly outside the room to monitor the patient. Because again, even though this patient’s screening was negative, you know, realize we questioned whether the accuracy of the screening because of the way it was administered, he did come in saying he was depressed. He does have a history of suicidal ideation. He does have a history of hospitalization due to previous suicide attempts, so again I would have wanted to at least keep eyes on this patient even if I couldn't do it directly by sitting in the room with him. I would put him in a room with at least more line of you know more direct line of sight so that someone could have laid eyes on this patient. The room he was in was in the corner, so you know it would have taken someone, would have had to make the effort to actually go past the room and look into the room to see the patient. It was just harder, harder to see the patient.

Fred Baker: And to the earlier point, the physician poked his head in, didn't see them, and left.

Trina Rollins: Exactly, so again, it's, you know, there were there was another room available that was that had more direct line of sight to the nurses' station that may have been a more appropriate room or again if it wasn't that busy checking in on the patient more frequently, even again every 15–20 minutes, even every hour, at least the patient—they would have been able to see the patient, but it was two and a half hours before this patient was found unconscious.

Fred Baker: So up to now, we've discussed missteps by individuals, but we also found that there were some deficiencies in leadership response to this. One of them was not conducting a thorough root cause analysis to the event and we've talked about this before in previous reports. Explain that and why that's so important.

Trina Rollins: Yeah, so a root cause analysis is important because again, you want to thoroughly evaluate why this incident happened. We know it was a tragic event and it happened in the emergency department inside the facility. So why did it happen? You know we've done OIG has done multiple inspections where we've had recommendations made about the way root cause analysis are conducted. Our Comprehensive Healthcare Inspection Program has reviewed at least one aspect of the RCA program (RCA the root cause analysis program) in six of the past eight fiscal years. Hotline has published 6 projects in this fiscal year alone that have some reference to a root cause analysis. Process error, so again it's a common issue and VA has very specific guidelines on how to conduct the root cause analysis.

Fred Baker: So, you, you and I discussed this there, this isn't an ambiguous process there.

Trina Rollins: No.

Fred Baker: There are steps. So, what, given the propensity obviously by facilities to not complete these correctly, at times. What is the incentive to not do it correctly? Well, or what is the explanation for not doing it by the standards?

Trina Rollins: So again, if it's not done correctly, there's no transparency to the evaluation so people can infer that maybe you're trying to. Cover up something. You know, in this case, one of the glaring errors is that they didn't have a subject matter expert on the RCA, meaning they had no one with emergency department experience actually as part of the RCA team. And we're told that the RCA team brought this up, but we're told by leadership to just move forward because they wanted to get the investigation going. You know, as part of an RCA you actually write up a charter and it explains in the charter who is going to be part of the RCA team. They made that reference in the charter there is supposed to be an emergency department staff person as part of the RCA team. It's written into the charter. But again, you're, you know, on the flip side of that, you don't want someone with direct patient care regarding this patient. So, it couldn't be the emergency department doctor that was supposed to take care of the patient or either of the two nurses that had been present during that the time frame that the patient had been there. But again, the emergency department has lots of other staff, they could have chosen from to be part of the team.

Fred Baker: Back another facility deficiency we, we determined, was the lack of a timely institutional disclosure and we've talked about this in previous reports, briefly explain what those are and why it's important to do those timely.

Trina Rollins: So, this is this is important and institutional disclosure basically is a facility admitting that something went wrong and caused a tragic error. You know, in this case this death occurred that they investigated the. Death and there were. Missteps that occurred by facility staff that you know in good possibility could have prevented the tragedy from happening and so VHA mandates that you make that type of disclosure to the patient. Again, it doesn't necessarily have to be a death. It could be an amputation. You know, you've heard in the news previously of people having the wrong leg operated on or the wrong arm operated on. Again, this is when an institutional disclosure is important. The process that was in place prior to the operation didn't occur and so they have to admit their error. And with an institutional disclosure, they're telling the patient if the patient is still alive and with cognitive function and ability to understand if not, they're their patient representative, their family member, you know their guardian, whoever is appropriate here's this information gets this information from the facility what steps were missed that contributed to this tragedy? And part of that also is giving the patient, the family member, the representative, the guardian, the information that they have the right to file a tort claim – a lawsuit against VA because of the error that occurred. And you know this death occurred in the fall of 2021. As of fall of 2022, the institutional disclosure still hadn't been completed. I didn't open the chart again just because I don't have a medical need to actually open it right now. So again, there's a privacy issue that's in play here, but our team, as they were doing their work and going through publication the last time they checked the medical record fall of 2022 a year later, the institutional disclosure still had not been completed appropriately.

Fred Baker: Wow. Wow. So, one other point I want to discuss before we get to the recommendations is so nurse one, the nurse we talked about who first administered the screening. We believe incorrectly, purportedly notified the physician when there's no, the video camera or the video, said otherwise. What happened to that nurse, one would think that there would be some sort of action taken for the nurse.

Trina Rollins: So, this is another misstep that we identified. The nurse actually resigned and there's no issue with that. You know a person under investigation can resign. But the issue is that their employment record was not marked resigned while under investigation. It was just marked as a plain resigned so that goes with them. So, if this nurse were to apply at another VA facility, that VA facility would have no knowledge that this nurse had been under investigation previously. And the next step in that is when the facility completed their own internal reviews, their RCA and administrative investigation, there was a recommendation to report this nurse to the state licensing board. This particular nurse actually had three licenses in three different states, or, you know, nursing licenses in three different states. So, the way this played out, the nurse executive made the decision not to report the nurse to the state licensing board. This has been an issue in in many of our reports of going through the process of reporting these providers, these nurses, social workers, whoever it is that didn't do their job properly to the state licensing board. The reason given by the nurse exec on this one was that they felt this was a conduct issue. But VHA policy is very clear whether it's conduct or clinical practice, they still need to be reported to the state licensing board and it just didn't happen in this case.

Fred Baker: And to be clear, this is this is a recommendation from the facility's own administrative investigation.

Trina Rollins: Correct. Yeah.

Fred Baker: So, in reality, nurse one could be practicing in any one of those three states.

Trina Rollins: Could be practicing in one of three states, yes.

Fred Baker: Very, very sad. So, what were our recommendations?

Trina Rollins: So, most of the recommendations had to do with the issues that we've already covered. Standardizing the process for administering the suicide risk screening. Developing a formal policy about expectations on the frequency of monitoring patients in the emergency department, ensuring RCA and administrative investigations are conducted appropriately, ensuring their institutional disclosures are conducted appropriately and then complying with reporting healthcare providers or healthcare professionals to state licensing boards when necessary. The one thing we didn't cover that we made a recommendation on is there was an issue within this that was possibly what we would call interference with our inspection. We were notified by VA's Office of Accountability and Whistleblower Protection that the chief of the emergency department sent an e-mail out to a staff physician directing that physician on how to respond to the OIG questioning. And basically, the response was you should be responding with yes, no, I don't know, or I don't remember. And so again, you can imagine if OIG is questioning someone and those were the responses, they were getting we would have very little information to make a determination about this investigation. So, we had to, we actually went back and reinterviewed 11 different individuals to assess whether or not this e-mail had any impact on their responses in in their interviews with us. We didn't find any changes in the responses of these individuals, but we still directed the facility to conduct a fact-finding investigation to determine whether the emergency department chief’s conduct was inconsistent with a policy and federal regulations about prejudicial conduct.

Fred Baker: So, given that how did the how did the facility respond to the report?

Trina Rollins: They had already done two internal reviews, the RCA, and the administrative investigations. So, they concurred with all of our recommendations. You know, some of which they had already made internal recommendations to fix. I do know they have already started working on these processes, so again writing a new policy is not as a quick a process as it seems you know these policies again have to have certain legal language in them and have to be reviewed by various different departments before they can actually be published to staff. So, it does take a little bit of time to get all of that review done and the appropriate language put into those policies.

Fred Baker: And we can continue to track these recommendations.

Trina Rollins: We will track all of these recommendations until we, OIG, feels that the facility is done the appropriate steps to maintain any of the changes that they have suggested to for the for the recommendation.

Fred Baker: Well, Trina again, it's another very tragic report with many learning points. Thank you very much for joining me and helping walk us through this report.

Trina Rollins: Thanks, Fred. I appreciate it.

Fred Baker: As mentioned in this podcast, you can submit a complaint to the VA OIG by phone 1-800-488-8244 or you can go to our website, www.va.gov/OIG/hotline, and fill out a hotline complaint there. However, if you are a veteran in crisis or someone who is concerned about one, please call the Veteran Crisis Line, dial 988 and then press 1. With that, I'll turn this podcast over to my co-host Mary, and she'll provide the updates from our most recent oversight work.

Mary Estacion: Thanks Fred.

Deputy Inspector General David Case testified on July 12 before the House Committee on Veterans’ Affairs or HVAC Subcommittee on Oversight and Investigations. His testimony focused on the importance of H.R. 2733, the “Department of Veterans Affairs Office of Inspector General Training Act of 2023,” which would mandate that all new VA personnel receive training on their responsibilities for reporting potential crimes and other wrongdoing, as well as how to engage with OIG oversight staff. It must be completed within the first year of employment. More than 385,000 established VA personnel have taken the training as of June 26, 2023, following a memo from Secretary McDonough, with overwhelmingly positive reviews. Mr. Case noted in his testimony that institutionalizing the OIG training would empower VA employees to report issues that impede the quality and timing of VA services and benefits received by veterans, their families, caregivers, and survivors. His written congressional statement has been added to the archive of congressional statements on our website, va.gov/oig. Watch the entire hearing on the committee’s website.

Stephen Bracci, director of the Claims and Medical Exams Inspection Division within the OIG’s Office of Audits and Evaluations, testified on July 27 before the HVAC’s Subcommittee on Disability Assistance and Memorial Affairs. His testimony related to the medical exams for veterans who file claims for disability benefits, which provide critical evidence of a connection between the claimed disability and the veteran’s military service and also help determine the degree of the disability’s severity. The resulting disability rating in turn defines the monthly monetary benefit the veteran receives. Mr. Bracci’s testimony focused on findings and recommendations from three OIG reports that illustrate gaps and limitations in Veterans Benefits Administration’s oversight of contractors who perform the exams for VA. The first report is a comprehensive review that concluded the identified lack of VA oversight on contract exam providers’ accuracy and lack of systemic corrective action put veterans at risk for inaccurate decisions. The other two reports describe more specific concerns: the need to better monitor the distance veterans must travel for exams and (2) to address the backlog of exams and errors from canceled exams that flowed from the pandemic. Mr. Bracci also discussed the impact the identified weaknesses can have on veterans’ experience with the disability benefits claims process and the steps VA must take to effectively implement open OIG recommendations. This hearing can be viewed in its entirety on the committee’s website.

Now for some news from the Office of Investigations:

A multiagency investigation resulted in charges alleging that numerous defendants—including pharmacists, physicians, recruiters, and beneficiaries—participated in a scheme to defraud federal healthcare programs by billing for nonreimbursable medications in compounded prescriptions. Coconspirators from a compounding pharmacy in the Dallas–Fort Worth area recruited beneficiaries to visit specific physicians and receive a prescription for compounded pain medication. These prescriptions were filled by the pharmacy, who then fraudulently billed VA and other federal programs. This investigation revealed that the medications contained several nonreimbursable ingredients and that the pharmacy overcharged for the medications. After the pharmacy was reimbursed for the medication, the beneficiaries, physicians, and recruiters were then paid a percentage of the proceeds. The total loss to the government is estimated at over $75 million, including an approximate $3 million loss to VA. The owner of the compounding pharmacy was found guilty in the Northern District of Texas on charges of payment of kickbacks and conspiracy to launder monetary instruments. This investigation was conducted by the VA OIG, Defense Criminal Investigative Service or DCIS, Department of Health and Human Services OIG, FBI, and Department of Labor OIG.

Another multiagency investigation resulted in charges alleging that multiple defendants participated in a scheme to defraud federal healthcare programs by submitting more than 1,700 claims for services that were not rendered, as well as other claims that were administered by individuals who were not appropriately licensed to perform the treatment. The total loss to the government is approximately $413,000. Of this amount, the loss to VA is about $250,000. Two defendants were indicted in the Middle District of Georgia on charges of healthcare fraud and conspiracy to obstruct justice. One of the defendants was also indicted for aggravated identity theft. This investigation was conducted by the VA OIG, DCIS, Department of Health and Human Services OIG, and the Georgia Medicaid Fraud Control Unit.
From November 1993 to July 2023, a defendant received VA Dependency and Indemnity Compensation benefits intended for his deceased grandmother. The deceased beneficiary was a recipient of VA benefits due to the military service of both her husband and son. A review of the deceased beneficiary’s bank records revealed that for nearly 30 years, the defendant used her VA benefits for his own personal expenses. The loss to VA is more than $340,000. Following an investigation by the VA OIG, the defendant pleaded guilty in the Western District of Missouri to theft of government property.

A multiagency investigation conducted by the VA OIG, DOL OIG, US Postal Service OIG, and the Defense Criminal Investigative Service resulted in charges alleging that a Texas company recruited injured federal workers by offering to assist in filing their claims with the DOL’s Office of Workers’ Compensation Programs. The defendants allegedly funneled those employees to medical clinics where doctors wrote prescriptions for compounded medications in exchange for kickbacks from pharmacies. The coconspirators allegedly billed DOL, as well as the Department of Defense’s TRICARE program, for more than $126 million. The portion of the billed amount attributable to VA employees is approximately $1.3 million. Four defendants were sentenced in the Southern District of Texas to 150 months in prison, 11 years of supervised release, and restitution of $24 million.

This month’s featured report from the Office of Healthcare Inspections focuses on the West Haven VA Medical Center in Connecticut and how the facility’s leaders failed in their response to an oxygen disruption. The OIG conducted a healthcare inspection to assess allegations regarding a disruption to the facility’s oxygen line. The line became unavailable when a construction company cut it. While relying on portable tanks, a patient experienced an adverse event and ultimately died after a period of inadequate oxygen supply. Contributing factors included a lack of accessible equipment, education, and training. The OIG was unable to determine if the adverse event caused the patient’s unresponsiveness or death. The report includes 12 recommendations related to communication, emergency preparedness, oversight, and response to the oxygen disruption.

From the Office of Audits and Evaluations comes a report about the Northern Arizona VA Healthcare System. The OIG inspected its information security to assess whether it met federal information security requirements and found deficiencies with configuration management, security management, and access controls. Configuration management issues could deprive users of reliable information access and risk unauthorized access or damage to critical systems. Also, the OIG identified almost twice as many devices on the network than the inventory listed. Weak access controls included missing video surveillance, inadequate fire-control equipment, and insufficient climate controls. The OIG made six recommendations to the assistant secretary for information and technology and chief information officer to improve controls at the healthcare system and five recommendations to the system’s director.
The Comprehensive Healthcare Inspection Program (CHIP) continues to be a critical element of the OIG’s overall efforts to ensure that the nation’s veterans receive high-quality and timely VA healthcare services. The inspections are performed approximately every three years for each facility. The OIG selects and evaluates specific areas of focus on a rotating basis. This month’s CHIP reports focused on the VA Central California Health Care System in Fresno.

For more information about these and the other activities the VA OIG has been working on, go to our website at va.gov/oig. If you want to get e-mails whenever the VA OIG publishes a new report or issues a congressional statement, you can sign up with GovDelivery by going to our website and click on email alerts under the section labeled stay connected.

Check out other episodes wherever you listen to podcasts. Stay tuned for more highlights next month. Thanks for listening.

This has been an official podcast of the VA Office of Inspector General. Veteran Oversight Now is produced by the Office of Communications and Public Affairs and is available at va.gov/OIG. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. Check out the website for more on the VA OIG oversight mission, read current reports and keep up to date on the latest criminal investigations. Report potential crimes related to VA waste or mismanagement, potential violations of laws, rules or regulations, or risks to patients, employees, or property to the OIG online or call the hotline at 1-800-488-8244. If you are a veteran in crisis or concerned about one, call the Veterans Crisis Line at 1-800-273-8255, press one and speak with a qualified responder now.