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 will bring you highlights of the VA 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 so much, Fred. I appreciate the invitation to be part of the podcast.
Fred Baker
We were very happy to have you. Trina let's open by first giving the listeners a little bit about your office and the types of cases that it handles.
Trina Rollins
So, if the listener isn't aware, VA stakeholders, as well as the public, can refer any concerns they may have about the Veterans Health Administration or their local VA to the VA Office of Inspector General for review. Any concern that is healthcare related comes to my team within the VA OIG's Office of Healthcare Inspection. I have a team of four nurses and a physical therapist that does the initial review, which we call a triage. And then if we have things that are a bit more complicated, either medically or mental health related concerns we will discuss those cases in a standing meeting we hold twice weekly. We have medical and surgical physicians as well as psychiatrists as part of our team and they attend those meetings and then our healthcare inspectors actually review and present the concerns for the group.
The intent is to have a thoughtful discussion about the details of the concern and decide as a group how we should disposition the case. Most of our hotline inspection reports that you find published on the VA OIG's public website were discussed in our working group prior to becoming an inspection.
Fred Baker
So, you have about how many staff?
Trina Rollins
I have five staff that are doing the initial triage review and then approximately 50/55 hotline staff, which actually perform the inspections.
Fred Baker
And these are our primarily medical professionals, correct?
Trina Rollins
Primarily, yes, we the majority of the staff are nurses or social workers, but we do have speech therapist, audiologists, and pharmacists as part of our teams as well.
Fred Baker
And just as a point of curiosity. Do they typically come to you from VA, or do they come from the private sector or straight? Out of out of school where, where? How do you where do you recruit these individuals?
Trina Rollins
The majority of our staff have worked at some VA facility prior to coming to OIG. I would say probably 85 percent have so they understand the language, they understand the computer system that VA uses for their medical records. They understand where to find the directives and handbooks that VHA puts out as their guidance. So, those that don't have that experience, they, you know, they have to take that time to learn it and get familiar with it when they start with us.
Fred Baker
So, this team is a pretty, well educated, experienced group of medical professionals when it comes to really looking at VHA services.
Trina Rollins
Definitely, Like I said, most of them have worked there. A lot of our staff have worked in quality management and so do have a clear understanding of what VHA should be doing as required by their directives and handbooks and how that is put into place in the facilities.
Fred Baker
So, you mentioned it just briefly, you know, VA, the VA OIG has an overarching hotline. And then some of those referrals come down to you. Discuss if you will just the few ways that referrals come to your team and then we'll talk about how those referrals become reports.
Trina Rollins
We, VA OIG, has the overarching hotline system, which receives any complaint related to VHA. Their team will then review the complaint and if it has any healthcare related aspect to it, it gets referred to my team for review. For instance, in fiscal year 2022, we were referred about 4,700 referrals from VA OIG hotline and of those we opened approximately 40 inspections. Obviously, with the number that we receive, we just don't have the resources to do an inspection on every single one of the referrals we receive, but we picked those that our most egregious, or we'll have some type of system impact and those are the ones we decide to open.
Fred Baker
And you mentioned there were a couple of other ways for you to receive referrals.
Trina Rollins
Oh, yes, sorry, we can get congressionally referred hotlines, so congressional, you know, members of the Senate, members of the House, their staff can submit hotlines to our Congressional relations staff. And again, if they're healthcare related, they will come to my group to review. We can also open new hotlines as a result of a previous inspection. So, for instance, if our CHIP team, our comprehensive healthcare inspection program teams, are on site doing a review and they get an anonymous complaint about something that is not covered in their review, they will send it to my group for review, especially if they feel it poses some type of patient safety issue. So yeah, we can get them in various ways.
Fred Baker
So, what delineates what the hotline section does, versus maybe a National Review and a comprehensive healthcare inspection? What makes a hotline referral, a hotline referral?
Trina Rollins
So, the comprehensive healthcare inspections are cyclical reviews. Those reviews are planned out, you know, approximately one year in advance, they're formulating their review guides and they know exactly the data that they're going to be reviewing for that inspection. And then the facility is notified a little bit in advance. But you know they're on notice that the inspection teams could come at any time. With national reviews, it's a project that is overarching and impacts all the VHA facilities. Our hotline work is more targeted to a single facility and is related to a more urgent or contemporary problem that has been discovered.
Fred Baker
So, you said that you can get referrals from teams that are on location, who get information that they feel it is maybe out of the scope of what they're doing then at that time and those come to you. Tell us about the report that we're going to talk about today, Deficiencies in the Patient Safety Program and Oversight Provided by Facility and Vision Leadership at the Tuscaloosa VA Medical Center in Alabama. That's a long title but start by telling me how this came to the hotline to the section.
Trina Rollins
Sure, this report was one of those few hotline inspections that was not discussed within our working group while on site at Tuscaloosa conducting a completely different inspection for another project. The inspection team received a copy of an issue brief outlining patient safety, management concerns, and programmed deficiencies at the facility, which then prompted us to open a second, separate inspection to review those concerns.
Fred Baker
Before we get into the details, which I have a couple questions I want to ask you. Can you give me some context? Give the listener some content to describe the facility for the listeners in, in terms of size and a number of beds, things like that.
Trina Rollins
Yeah, I sure can. So, Tuscaloosa VA Medical Center is located in Tuscaloosa, AL, and the facility is part of Veterans Integrated Surface Network 7. VISN 7 is the acronym. And it's located on a 125-acre campus. The medical center has 317 operating beds, which includes 43 inpatient mental health beds, 134 community living center beds, 128 domiciliary beds and 12 compensated work therapy transitional residence beds. It's designated a Level 3 low complexity and provides primary care, mental healthcare, and long-term and rehabilitative care for veterans.
Fred Baker
So, with respect to other healthcare facilities, is this a large one, small one, middle of the road?
Trina Rollins
It's a small facility, actually, a level 3 lower complexity. If you heard, they don't actually have any inpatient acute beds, so no acute medical care, inpatient beds, just inpatient mental health beds and then their community living center and domiciliary beds.
Fred Baker
And about how many patients roughly a year do they serve?
Trina Rollins
I believe 15,000.
Fred Baker
Ok. Perfect.
Trina Rollins
I didn't look it.
Fred Baker
Yeah, I think I think that's what I was about 15,000. Another hotline team was there. They were doing an inspection. You mentioned an issue brief, so explain to the listeners what that is.
Trina Rollins
Sure, this is a document prepared by a VA facility to provide information to leadership within VHA regarding some type of situation that's occurred. Issue briefs should provide clear, concise, and factual information about the subject and may impact patient care or actually may generate media attention. So, things that may trigger a facility doing an issue brief or submitting an issue brief is an emergency affecting VA, like a weather condition or a terrorism type condition, a homicide or suicide on a property. In this case something impacting clinical care of patients.
Fred Baker
So, this was something that was prepared for VHA by the facility that that about an instance that impacted clinical care. So, explain what that was.
Trina Rollins
Can I give you a little bit of background on the patient safety program?
Fred Baker
Sure. Absolutely. Yeah. Provide context.
Trina Rollins
The issue brief was about the patient safety management program and VHA leaders are responsible for ensuring that patient safety is a priority at each facility. And they can only attain this by creating a culture of safety where all staff share responsibility and minimizing harm to patients. This is an important element of the culture of safety and an important element of the culture of safety is the just culture, which is an environment where employees assume accountability for reporting issues that they feel may be unsafe. The basic tenant of a patient safety program is reporting concerns. The goal of VHA patient safety program is to prevent harm to patients. They do this by prevention of adverse events and developing this culture of safety. So, facility leaders have the responsibility to create this culture where employees are able to report concerns without the default response being to blame or to punish. VHA requires facility patient safety programs to identify and report events. Again, that's what you know what they're trying to elicit from all staff. The patient safety managers determine a cause, disseminate any patient safety alert information, conduct risk assessments, and then implement effective practices to mitigate those risks. And at the end of the year, they will then submit an end of fiscal year patient safety annual report. And in all of this, the patient safety manager is the manager. They oversee and coordinate this process for the facility.
Fred Baker
And that position was at the center of this issue brief.
Trina Rollins
Correct
So, talk then a little bit about what was the concern with the patient safety manager…former patient safety manager.
Trina Rollins
So, with this inspection, the VA OIG found that the former patient safety management manager was quote derelict in the performance of their duties and that both the facility and vision leaders performed inadequate oversight of the patient safety program. With regarding the duties of the patient safety managers, manager, I'll give one example from the report, in the summer of 2021, the former patient safety manager went on extended leave and then abruptly retired approximately five weeks later. So, in the meantime, the facility had to name an acting patient safety manager and it was this person who found that over 160 JPSR's and this is joint patient safety reporting events were still open, meaning that the requisite review of the event had not been completed. The JPSR IS VHA's patient safety reporting system and database, and it is the way that employees can anonymously, or they can identify themselves report any type of incident that they feel impacts patient care.
Fred Baker
So, to be clear, these were reports that were completed by employees. But nothing had…
Trina Rollins
Sent to the patient safety manager.
Fred Baker
Sent to the sent to the patient safety manager and nothing was done.
Trina Rollins
Correct. So, the duties of the patient safety manager is to review that JPSR, determine if the concern is patient safety related or if it needs to be redirected to a different department, and if the concern is patient safety direct related, then the patient safety manager assigns what's called a safety assessment code. A fact score and these are risk assessment scores assigned for any adverse event or close call that occurs, and the severity score is on a scale of one to three, three being the worst, and it's a sign based on the condition of the patient after experiencing the patient safety event and that could be a minor, moderate, major or catastrophic event, catastrophic, usually meaning a death has occurred and then the probability of that event reoccurring. So, it could be remote, uncommon, occasional, or frequent. So, after assessing that fact score, then the issues actually supposed to be assigned an investigator and reviewed and then all of that information is gathered to understand the concern and why or how it happened. This total review should occur within 14 days, but we found in our data review that the majority of the reviews were late, and some were incomplete. There were inconsistencies in the management of the events including the categorization which similar events were grouped. And events that represented potential delays in care that should warrant further investigation were rejected by the patient safety manager. So that's really important because two years’ worth of this JPSR data showed 100 percent of the final event reviews lacked the documentation required to be considered a complete investigation, which then calls into question the thoroughness of the investigation, and again, there's no way there for the facility to know if the system vulnerability was ever addressed, leading to more patient safety events.
Fred Baker
Right. Wow, so did you all conduct this inspection?
Trina Rollins
So, the inspection team reviewed a lot of documents, policies, meeting minutes, performance reviews. They conducted a virtual site visit and then interviewed staff and leaders, leaders at the facility, VISN leaders as well as National Center for Patient Safety staff in order to get the information needed for this inspection. One other interesting fact about this inspection is that VA OIG had to use its testimonial subpoena authority to compel the former patient safety manager to be interviewed for this inspection.
Fred Baker
So just so the listener knows that once a former employee is no longer with VA, they can't be compelled. Previously, they could not be compelled to provide testimony. Just recently, there was legislation passed, congressional legislation passed, that gave us, the VA OIG, subpoena authority that, that legally compels them to testify, even if they are former employees.
Trina Rollins
Correct. Yeah. Thanks for that.
Fred Baker
No problem. So, what I also found interesting in in the findings of this report is that this facility had already had issues identified by the OIG with their patient safety program, correct.
Trina Rollins
Exactly. Pretty much the same issues too, so that that's the interesting part. Our FY2019, fiscal year 2019 CHIP, the facility had only completed six of their required eight root cause analysis, which limited the opportunities for the facility to identify and improve system vulnerabilities. None of those RCA's contained all the required elements, resulting in inefficient evaluation of patient safety events, and again, limiting the analysis of the system vulnerabilities. And then those completed RCAs did not have corrected items identified and implemented as required, which could then result in future occurrences of similar events. So, at that time, though VA OIG made four recommendations requiring the patient safety manager ensures completion of the required minimum eight root cause analysis each fiscal year and monitors the patient safety managers compliance with that, ensures that those RCAs include all required elements, and ensures corrective actions are implemented and monitored for sustained improvement. And I'll explain a little bit why that's very important. And then finally ensures that the patient safety manager provides feedback to those who submitted the JPSRs that result in RCAs.
Moving forward one year, CHIP did another review of this facility. So, in FY2020 they had repeat findings for all of the RCA issues. So, none of their five root cause analysis completed in FY20 20 included all of the required elements. And the documentation was such that we couldn't even determine if the individuals directly involved in the adverse event had been excluded from the review process. Three of the RCAs had action items implemented, but none had outcomes showing sustained improvement. Four of the five RCAs lacked documentation, that feedback, regarding actions was taken to provide the individual or department reporting the event. So again, they are required to do eight RCAs per year. They only completed five, and of those five, you could tell none of them were fully completed. So, no new recommendations were made in FY2020 because all of the recommendations from FY2019 were still open, and then again without showing sustained improvement of their action items, we received that alert from the issue brief in September of 2021, that shows the importance of monitoring any action for a sustained improvement?
Fred Baker
And that's where it really dropped. They started it, but they never monitored it— leadership.
Trina Rollins
Well, they created action items, which is a requirement. When we have a recommendation, it's required that VHA develop some type of plan to address the recommendation, and it is always our recommendation too that they monitor the action for sustained improvement and OIG can only follow an issue so long.
These recommendations were already open one year and then a year later they had similar, if not the exact same recommendations. And then one year later, we find the same issues again. So again, since when you create an action plan, it really should be something that you can monitor and sustain and show improvement of.
Fred Baker
So, what was VA's response to these recommendations?
Trina Rollins
We made recommendations at three different levels. We made four recommendations to the Under Secretary of Health. Two to the VISN director and five to the facilities director. And I thought that the under secretary of Health was actually very positive with his response. The VA OIG's reported highlighted opportunities to improve not only the patient safety program at the Tuscaloosa VA Medical Center, but also at the national level. So, they made changes by updating the patient safety handbook to a quality and patient safety directive, which is a national directive, and that policy is currently in its final stages of review, and it should be, or they hope to have it completed, by later in this calendar year.
Another change they made was that the National Center for Patient Safety at which is again establishing a work group to evaluate patient safety data and develop enhanced oversight processes for dissemination across all VISNs and all facilities. I just wanted to highlight some of the changes at the VISN level. When reading the report, you'll see that there were some conflicts or inconsistencies with the duties of the patient safety officer at the VISN level. So that, that person should have oversight of the patient safety managers at the facilities within that VISN and should be monitoring the data, and you know, hopefully using that data to proactively find any issues and address those issues. So, the VISN director determined that the patient safety officer will start reviewing JPSR timeliness, meaning you know is that JPSR being reviewed in that 14-day time frame, and if it's not, why? The patient safety officer will determine whether or not the JPSR reviews were investigated by subject matter experts and providing feedback to the person that actually reported the event. And then the patient safety officer should look at key patient safety analysis and content. So again, looking for any type of trend in patient safety events and then monitoring the action implementation and sustainment from the patient safety analysis. So, all of this should also be tracked and then reported at a VISN level committee called the Patient Safety Subcommittee and then reported up to the Quality Safety Value Council, which is again a VISN oversight committee.
Fred Baker
So, what are our next steps? We've identified, you know, at least three different times and made recommendations, the first time, none the second, and now recommendations all the way up to the under secretary for health. What are our next steps?
Trina Rollins
Part of that was the recommendations, you know, making recommendations to the under secretary of health does not come lightly. We found some gaps in the policies that with changes that they're making currently will help remove those gaps and provide additional guidance to VISNs and facilities. So, that's why we made those recommendations to the under secretary of health.
I think overall we feel that with our review, we're optimistic that the patient safety programs at the facility and that VISN 7 has taken steps to improve their compliance. When you read the report, you see that leadership at the facility and the VISN level just didn't have a clear understanding of their job duties when related to the patient safety program. When we went through our review, we were pointing these things out and they admitted to a lack of understanding. And so, I think, you know, if nothing else, this report will help to bring forth all of the complexities and the specific requirements of facility patient safety programs as well as the requirements for oversight at the VISN level; just kind of brought all of that to the forefront and made those staff more aware of it. So, 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.
Fred Baker
Well, Trina, thank you very much for coming on and talking about this report. It sounds like a very important report as we push VHA toward adopting a culture of patient safety. Do you have anything else you'd like to add?
Trina Rollins
No, I just again, I just wanted to thank you for allowing me to come on the podcast and highlighting this report. I think it's a very impactful report.
Fred Baker
Well, thank you very much, and we'll have you on again.
Trina Rollins
Thanks Fred.
Fred Baker
Well, thank you again Trina for joining us. 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
Thanks Fred. Here are some highlights for May.

The VA Inspector General Michael J. Missal testified before the House Veterans’ Affairs Committee on May 23, 2023. The hearing focused on whether COVID-19 supplemental funding protected and improved veteran care. IG Missal spoke about the findings and recommendations in numerous OIG reports that covered VA’s expenditure of supplemental funds, as well as the adjustments VA made to deliver health care during the pandemic. He emphasized the need for VA to deploy a modernized financial management system and to promote greater staff adherence to policy. In response to questions, IG Missal discussed the importance of training and internal controls, VA’s pivot to telehealth, and OIG criminal investigations that addressed pandemic-related fraud targeting VA.

From the Office of Inspections comes a guilty plea from a former VA pharmacist in connection with a fraud scheme. Between May 2017 and June 2018, a former Office of Community Care benefits adviser referred more than 40 spina bifida beneficiaries to unlicensed home health agencies owned by friends or relatives, including a pharmacist working at the VA medical center in Aurora, Colorado. These unlawful referrals led to payments totaling approximately $19 million from VA to these home health agencies. The pharmacist pleaded guilty in the District of Colorado to conspiracy to commit acts affecting a personal financial interest. As part of the plea agreement, the pharmacist resigned his VA position and agreed not to seek or hold federal employment for the term of the sentence imposed by the court. He also agreed to pay restitution of more than $600,000 and not to contest a prior asset forfeiture in the amount of almost $1.6 million. The VA OIG, Internal Revenue Service (IRS) Criminal Investigation, and FBI conducted the investigation.

The VA OIG investigated a business that claimed to provide home health services to veterans but was submitting, on behalf of unwitting VA beneficiaries, fraudulent applications to VA for pension with aid and attendance benefits. Aid and attendance is a higher monthly pension amount paid to a qualified veteran or surviving spouse for assistance with activities of daily living. The co-conspirators received more than $2.1 million in VA funds intended for more than 70 veterans or their surviving spouses. The defendants pleaded guilty in the Eastern District of Louisiana to wire fraud.

VAOIG investigators found that a former Arkansas state senator participated in a conspiracy to enrich himself and others through a nonprofit organization that contracted with VA to provide substance use counseling and housing services for veterans. As part of the conspiracy, the then state senator was hired by the nonprofit organization to also act as outside counsel. In exchange for payments and the commitment to pay for legal work, he performed official acts on behalf of the nonprofit organization, including holding up agency budgets and drafting and voting on legislation. From 2010 to 2016, the nonprofit had revenues of approximately $837 million, to include $1.7 million contributed by VA. The former state senator was sentenced in the Western District of Missouri to 50 months’ incarceration, three years’ supervised release, and returned more than $468,000 after pleading guilty to conspiracy. The investigation was conducted by multiple oversight agencies from the VA, Department of Labor, Housing and Urban Development, Federal Deposit Insurance Corporation, and Health and Human Services, as well as the Medicaid Fraud Control Unit of the Missouri Attorney General’s Office, IRS Criminal Investigation, and FBI.

The OIG reviewed VA’s information security program for FY 2022 for compliance with the Federal Information Security Modernization Act. After evaluating 47 major applications and general support systems hosted at 23 VA sites and on the VA Enterprise Cloud, the OIG determined that VA continues to face significant challenges meeting requirements. These deficiencies can be remedied by improving the deployment of security patches, system upgrades, and system configurations; enhancing performance monitoring; and addressing security-related issues. VA concurred with the OIG’s 26 recommendations.
An audit of VA’s control over supplemental funds led to the review of how VHA used $17.2 billion dollars as part of the CARES Act, or Coronavirus Aid, Relief, and Economic Security Act. VAOIG auditors found that VHA did not develop guidance for the type of documentation required and staff could not always identify what was purchased or provide evidence the purchase was a proper use of funds. Therefore, the OIG questioned an estimated $187.2 million. Congress lacks assurance that funds allocated for veterans’ COVID-19-related care are being spent as intended. The OIG recommended VA assess whether it can integrate its financial management system with other systems to reduce the need for expenditure transfers; the OIG also made eight recommendations to VHA to improve oversight of supplemental funds.

Work by the VAOIG Office of Healthcare Inspections looked at issues at the VA Black Hills Health Care System in Fort Meade and Hot Springs, South Dakota.
One inspection evaluated facility leaders’ response to an administrative investigation board’s (or AIB) findings and recommendations. In response to complaints alleging failures in leadership and management, misconduct, and inappropriate relationships between leaders and staff and between clinical staff and patients within the Mental Health Service, the then facility director convened an AIB, which made 11 recommendations. Following the retirement of the facility director, senior facility leaders (including the acting facility director) did not follow up on the recommendations. When the OIG became involved, facility leaders read the AIB report and developed an action plan for the recommendations.
The OIG made two recommendations to monitor and track the action plans to completion and to independently determine if the state licensing board should be notified.

Another inspection at the Black Hills Healthcare System evaluated the administrative and clinical responses by leaders and staff to a patient’s allegations of sexual harassment. The patient was participating in VA’s Compensated Work Therapy program and the Transitional Residence program when a food service coworker allegedly harassed the patient, who subsequently committed suicide. The OIG determined that facility leaders did not take administrative actions aligned with policy when the patient reported being sexually harassed. The VA OIG made three recommendations related to reviewing the sexual harassment policy and ensuring that the policy addresses the safety and rights of patients who are both VA employees and participants in the Transitional Residence program.

This month’s Comprehensive Healthcare Inspection or CHIP, reports focused on the following facilities:
Central Texas Veterans Health Care System in Temple
West Texas VA Health Care System in Big Spring
Tennessee Valley Healthcare System in Nashville
South Texas Veterans Health Care System in San Antonio
Northern Arizona VA Health Care System in Prescott
And the VA San Diego Healthcare System in California

Two Vet Center Inspection Program or VCIP reports were published in May. They focused on selected community-based clinics in Pennsylvania, West Virginia, Maryland, Virginia, and North Carolina.
For more information about these and the other reports the VA OIG have recently published, go to our website at va.gov/oig and select “reports” under the Publications tab.
To learn more about the VA OIG’s activities, including featured hotline cases, go to va.gov/oig and click on monthly highlights under the Publications tab. That’s it for this episode of Veteran Oversight Now.
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 1, and speak with a qualified responder now.