Veteran Oversight Now

Louis Calderon
Hello listeners. This month, on the Veteran Oversight Now podcast, we are publishing an “In Case You Missed It” episode. We’re reaching back and republishing one of our more popular episodes from February 2024, in which we discuss the healthcare inspection, Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona. This episode includes a conversation about the incident and dives into the associated healthcare inspection. Check out our website, vaoig.gov, for all previously published podcast episodes, or find us anywhere you normally listen to podcasts. Be sure to subscribe, and thanks for listening.
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 Health Care System for eight years prior to joining the VA OIG in 2011.
Trina, welcome to 2024.
Trina Rollins
Thanks, Fred. I’m glad to be back doing podcasts.
Fred Baker
Yes, well, we are back from an extended absence for the holidays and for some of the other products we were producing. We are glad to be back. We are here today to discuss the healthcare inspection, Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona. Trina, as we do on the other reports, for the audience, can you kind of describe the size of this healthcare system and give us a little context?
Trina Rollins
Sure. The Carl Hayden VA Medical Center is the VA in Phoenix. It has 10 associated outpatient clinics and is part of VISN 22. It is a 1A high-complexity-rated facility within VA and provides healthcare services, including primary care, long-term care, and specialty services, such as surgery, neurology, oncology, dentistry, geriatrics, nutrition, psychiatry, and physical medicine and rehabilitation.
Fred Baker
Great. Thank you very much. So as the name states, we’re here to talk about the delayed receipt of patients’ colorectal cancer screening tests. Start out, though, how did this hotline inspection end up in your office?
Trina Rollins
So, we actually got a complaint stating that there were over 400 of these test kits that were delayed and being delivered to the VA. And the back story on this is that the FIT test—if you’re not aware, a FIT test is a way of screening for colorectal cancer. And it is a home test where the patient receives the test from the VA, will take it home, and actually use the manufacturer’s directions to complete the test. It consists of taking a stool sample and packaging it, and then mailing it back to the VA.
Fred Baker
Mailing it back in a self-addressed, postage-paid envelope?
Trina Rollins
Correct. And so, yes. So those postage-paid envelopes will go to the US Postal Service and then get delivered to the VA. Well, in this case, unfortunately, there was a bill, an unpaid annual fee, and the Postal Service held onto these tests. And it wasn’t until a very conscientious US Postal Service employee noticed that these tests might be important and called the VA and said, “You know, you’ve got an outstanding bill here, and we’ve got a large number of these tests that need to be delivered.” And then that just snowballed into several other things that happened.
Fred Baker
So, before we go on, before we move into all that, let’s go back and talk about these tests and the importance of the role they play in ongoing health care for veterans.
Trina Rollins
Sure. So colorectal cancer is the third leading cause of death—cancer death—in both women and men in the United States. And most of the colorectal cancers arise from precancerous growths or polyps—I think most of our audience has actually heard of a polyp before—that form in the lining of the colon. And these polyps are normally noncancerous but, over time, could develop into cancer. So that’s the reason you want to get screened and get screened early. And the way to screen for colorectal cancer is two ways. One is a stool-based test, such as the FIT test, the fecal immunochemical test, that the VA uses.
Fred Baker
Which we’re talking about for the purposes of this.
Trina Rollins
Which we’re talking about for this project. Yes. And again, that test detects the presence of blood in the stool and having blood in your stool doesn’t necessarily mean you have colon cancer, but it is an indicator of that. So, it means if there’s blood in the stool, you want to get checked out and have further testing done in order to check for that cancer.
The other way to test for colon cancer is direct visualization through a colonoscopy.
Fred Baker
Sure.
Trina Rollins
So that’s, you know, an invasive procedure using a camera, and they go up into the colon and look around to check for any type of polyps or any masses that may indicate cancer. So, as I said just previously, the VA’s preferred method or the method that VA use preferentially is the FIT test, and they recommend screening patients from the age of 45 to 75.
Fred Baker
But it’s definitely, as far as preventative medical care, a very important test because if anything, if there is a positive that allows them to go to the next step, have a colonoscopy, have a more detailed test, and then they can proceed from there.
Trina Rollins
Exactly. And the screening test is recommended to be done annually.
Fred Baker
Sure.
Trina Rollins
So, the FIT test.
Fred Baker
So, and let’s talk about the number, too. I know there were over 400 tests that were at this non-VA warehouse. That sounds like a lot of tests for a medical system. Is that a lot?
Trina Rollins
Not necessarily. You know, with these tests, they were collected over a period of time. So, you know, when a patient gets the test, they can go home and do it immediately or they may want to wait a few days or, you know, if they’re going on vacation and decide, “I’m going to wait until I come back from vacation.” So, again, that time frame is dependent upon the patient, when they complete the test and when they pop that envelope into the mailbox.
Fred Baker
So, it’s a lot of tests, but it wasn’t necessarily a stockpile.
Trina Rollins
No. And then, you know, you got to realize, too, Phoenix, the size of Phoenix, and this is a screening test that’s meant to be done annually for patients between the ages of 45 and 75. So that’s, you know, quite a bit of the VA population. So, 400, you know, may actually be on the low side for a month or two.
Fred Baker
Right. I gotcha. So, before we get into the details of the who, what, when, where, how, let’s talk about the time sensitivity and then discuss the potential for false negatives a little bit.
Trina Rollins
Sure. So according to the FIT manufacturer’s guidelines, once the stool is collected and placed into the vial that is needed to carry the specimen, it’s only stable for about 15 days at room temperature. And if it’s refrigerated, then you can add another 15 days. So, it’s stable for about 30 days. But, you know, in reality, if you’re putting this in your mailbox and it’s being picked up by the Postal Service, it’s not going to be refrigerated. So, they have about a 15-day window to collect the sample and then process it and test it.
Fred Baker
And this storage facility was not a refrigerated storage facility?
Trina Rollins
No, it was not.
Fred Baker
So, we’re on a 15-day countdown.
Trina Rollins
Exactly. And then the reason for that is, you know, the test is looking for blood in the sample. Blood actually starts to degrade over time. So after about 15 days, even if there was blood in the stool, it would have degraded enough to where the test wouldn’t have been accurate. So, it could give you a false negative result.
Fred Baker
So more than 400 of these were held for about 60 days. That’s well outside of that stability period.
Trina Rollins
Exactly. Exactly.
Fred Baker
What happened to those?
Trina Rollins
So, when they got the test, the facility actually worked really quickly to identify all of the patients affected and developed a plan for follow-up. So, they had the names of all the patients, because on the vial of the stool sample, you actually have to—they had to put their name on the stool sample. So, they had the name of the veterans. They looked in their medical record to see if they had completed any type of colorectal cancer screening. And if they didn’t, then those patients were marked as needing to be rescreened. And so, what they did was send out a letter explaining to the veterans what happened and that their test couldn’t be processed and sent them a new test kit and this letter of explanation and asked the veteran to submit another sample for their screening test.
Fred Baker
So, it sounds like they took fairly prompt action on that part of it.
Trina Rollins
Really prompt on that part.
Fred Baker
Yeah. And you say it centered around an unpaid postage bill. Was this just a breakdown in communication?
Trina Rollins
Unfortunately, yes. What had happened was the supervisor for logistics was responsible for paying the bill. Well, the supervisor changed in March. The previous supervisor left in March. A new one wasn’t hired until April or didn’t come on board until April. So, there was this lack of communication during the transition. So, some knowledge was lost and realized the new supervisor didn’t realize that the bill was outstanding, and it wasn’t on their radar to pay until they actually got the notification from the US Postal Service. That has since been corrected, though, because, again, this is now—they move forward and set up an automatic payment system.
Fred Baker
Now it’s on autopay.
Trina Rollins
Exactly. So, there’s no risk of unpaid bills in the future.
Fred Baker
Now, there were some other allegations in this complaint that we didn’t substantiate, that were related to these samples, correct? Or these tests?
Trina Rollins
So, there was an allegation about a loss of protected information, but that was not substantiated—that the samples, again, in order to find out who the sample belonged to, the veteran had actually placed their name on the sample. And those samples were placed in the appropriate type of container to dispose of them appropriately. And so, that was not at risk for being lost or available to public use.
Fred Baker
But there was one additional concern that we found as we were working through this inspection, correct?
Trina Rollins
So, there were actually a couple.
Fred Baker
A couple?
Trina Rollins
Yeah, a couple because we found that the laboratory staff were misinformed or had a misunderstanding of the stability of the test kit. They felt the test kit, or they reported to us that they thought the test kit was viable for 30 days. But when you know, when looking at the manufacturer recommendations, it’s viable for 30 days in a refrigerated setting, but only 15 in a room temperature setting. So, but on top of that is determining what’s the start time for that 15-day period. What we found was that the vial for collection had a preprinted label on it, so it had the patient’s name and, you know, the appropriate identification for the patient, but didn’t have a place on there for the patient to actually mark the date they collected the sample.
Without that date, you don’t know when to start. You know, when does the clock start? The staff, the laboratory staff were using the date that they received the sample. Some staff were using the day the order was placed. So again, you can see where there’s variation in that. And so, again, we needed to ensure that there was a known start date. Otherwise, the testing, the reliability of the testing was at fault.
Fred Baker
So, just so we’re clear, were there samples that were tested outside of what would be viewed as their stability date?
Trina Rollins
Yes, previously there had been. Now, of the samples that were taken, that were from the Postal Service this time, there were three samples that had enough information on there to verify the collection date and be within the timeframe to actually be processed. The other 403, I believe, were not processed. So again, they didn’t go through the accession, meaning they weren’t linked back to the patient’s medical record. The testing of the sample didn’t actually occur. And so, with that, there was a lack of communication to the primary care providers who had ordered the test. You know, they had this order out, this outstanding order for this colorectal cancer screening test, but it was never actually done, even though the patient had sent in a sample. What should have happened was that the patient—the sample should have been assessed, linked to the initial order, and then a comment placed that the sample couldn’t be run and given a reason. And the reason would have been it was outside the stability period for the test.
Fred Baker
So, what were our recommendations?
Trina Rollins
Our recommendations, we had recommendations at the VISN level as well as the facility level. And we recommended the VISN provide oversight of the facility’s review of their laboratory processes related to this FIT test and processing of these tests, as well as evaluation of patient impact of the potential false negative results. Because remember, we pointed out that the lab staff had the misunderstanding that the tests were stable for 30 days, and then on top of that, they didn’t have an actual collection date that they could, you know, start the clock on. So, they ran many tests in the past with that incorrect knowledge. And so, it could have been that they had many false negatives during that time frame.
Fred Baker
So, we made a recommendation that they relook at that. Did they take any action on that yet?
Trina Rollins
They have. So, a couple of things have happened. The VISN actually led a stand-down at the facility to retrain all of the laboratory staff about the test, about the accessioning 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.
Fred Baker
Did we have any other recommendations?
Trina Rollins
We did. We had some recommendations for the facility to, again, review and ensure compliance with these FIT testing process, as well as doing an evaluation of the whole system, the process, and to determine if there’s any practices they needed to correct or if they could improve the process in any way. And then finally, to modify the facility’s preprinted label to include the date the specimen was collected. So, again, you know, they put the label on the vial in order to help the patient out. It’s identified. It’s got all the appropriate identifiers for the patient. But it didn’t have a place to put a date as to when the specimen was collected. So, they’ve since reprinted those FIT labels to include the date of the specimen collection. And I thought what was really interesting on this was they actually got the—they collaborated with the supplier of the FIT test to revise the collection instructions as well, so that it says in the instructions to make sure you put the collection date on your label.
Fred Baker
So, we actually cover a lot of pretty tough topics in this Hotline podcast. This actually sounds almost like a good news story in terms of the outcomes.
Trina Rollins
It’s good news in terms of the outcome, definitely. You know, the OIG staff had done a preliminary review and didn’t find any patient harm as a result of these delays. But we did recommend that the facility and VISN oversee a further look about that. And then again, you know, the processes that we found that were deficient, they made it—very quickly made changes in order to improve the process. And I’ll also say, too, VHA as a whole, VACO released an operational memorandum back in October of 2023 and gave guidance on what to do if the FIT tests or the test sample has a missing collection date. They actually provided language to put into the medical records so that the provider that’s ordering it and the patient, when they received their results, would have an understanding, you know, that the results could be impacted because they didn’t have a collection date on there.
Fred Baker
So, a lot of impact VHA-wide from this one oversight report.
Trina Rollins
Exactly. Exactly. Very positive.
Fred Baker
Great. Is there anything else you’d like to add, Trina?
Trina Rollins
No, I think that’s that covers it. I think it was, you know, a very interesting hotline and an interesting report, but again, made an impact at Phoenix with VISN 22 as well as VACO-wide.
Fred Baker
Well, thank you, Trina, for being here. As always, we appreciate your input, and we look forward to our next podcast.
Trina Rollins
Thanks, Fred.
Fred Baker
As mentioned in this podcast, you can submit a complaint to the VA OIG by phone at 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 Veterans Crisis Line. Dial 988 and then press 1. Now let’s go to Lauren for the highlights of our oversight work for this past month.
Lauren O’Connor
Thanks, Fred. September is often the busiest month of the year for the VA OIG, and this year was no different. OIG staff testified before the House Veterans’ Affairs Committee five times during the month.
Inspector General Michael Missal’s September 10 testimony before the HVAC focused on the need for VA to improve the five core elements of accountability that reflect effective leadership.
Inspector General Michael Missal
Our staff routinely finds breakdowns in leadership, governance, processes, staffing and other infrastructure, IT systems, and quality assurance programs that erode accountability. These breakdowns impede VA’s efforts to make certain that all patients receive timely, high-quality health care and that all veterans and other eligible beneficiaries are afforded the compensation and services they are owed. Some of the most concerning examples are found in medical centers.
Lauren O’Connor
He noted breakdowns in some or all of those core elements were found in recent healthcare inspections of VA medical centers such as Hampton, Virginia, and Aurora, Colorado.
On September 18, Dr. Julie Kroviak, principal deputy assistant inspector general for healthcare [inspections], testified before the HVAC’s Subcommittee on Health. Her testimony focused on a recent report looking at the Veterans Crisis Line’s—also known as VCL—transition to a three-digit dialing code.
Dr. Julie Kroviak
Our most recent report reviewed VA’s 2022 implementation of the National Suicide Prevention Hotline three-digit dialing code. Overall, our team found that VCL leaders provided their staff with the necessary equipment and technical support, and they significantly increased responder staffing to meet an anticipated increase in calls. We were also encouraged by VCL leaders’ quality data collection and analysis practices. We did find opportunity for VCL leaders and supervisors to be more supportive of frontline staff by assuring awareness and access to postvention resources. As with any crisis intervention service, the demands and expectations of responders are significant, and they must have access to resources that support their well-being and resilience.
Lauren O’Connor
Dr. Kroviak also spoke about a 2023 report concerning a veteran’s suicide after an inadequate suicide risk assessment by a VCL responder.
At a September 19 hearing before the Subcommittee on Technology Modernization, Dr. Jennifer McDonald, director of the Community Care Division in the OIG’s Office of Audits and Evaluations, spoke about the VHA Program Integrity Tool. She Specifically discussed the impact VHA’s pause in using the tool has had on community care revenue collections and oversight operations.
The following week, Dr. Jennifer Baptiste, deputy assistant inspector general for the Office of Healthcare Inspections, testified before the Subcommittee on Oversight and Investigations, about recent healthcare inspection reports detailing serious issues at the Hampton VA Medical Center in Virginia. The three reports uncovered lapses in care coordination, communication, quality of care, administrative and clinical oversight, quality assurance, and overall employee engagement. She emphasized the need for a more proactive role for all VISN leaders to ensure facilities are appropriately monitored and have the resources needed to provide high-quality health care.
Finally, Nicholas Dahl, deputy assistant inspector general for Management and Administration and chief information officer, testified on September 26 before the Subcommittee on Economic Opportunity. His testimony focused on findings in a recent OIG report on VBA’s oversight of the Digital GI Bill platform, a system designed to improve education benefits delivery. Mr. Dahl discussed how inadequate planning led to underdeveloped and unrealistic contract requirements and terms that resulted in significant delays and more than doubled the original contract cost.
In addition to these testimonies, Inspector General Missal published a statement for the record for the congressional hearing, “Examining VA’s Challenges with Ensuring Quality Contract Disability Compensation Examinations.” His statement focused on several reports the OIG has published in recent years that address concerns about the veterans’ experience with the claims process.
All of the OIG’s written statements to Congress can be found in the congressional relations section of the OIG website, and you can watch our opening statements at our YouTube Channel, @VetAffairsOIG.
Nine OIG investigations had updates in September.
One VA OIG investigation revealed a former medical supply company owner paid kickbacks of over $36,000 to a former Central Supply Department supervisor at the Jesse Brown VA Medical Center in Chicago in exchange for their initiation and approval of orders from his company for products that were never delivered to VA. He was sentenced in the Northern District of Illinois to 24 months’ imprisonment and 24 months’ supervised release after pleading guilty to wire fraud. The former VA supervisor was previously sentenced to 84 months in prison and 36 months’ supervised release. Both defendants were ordered to jointly pay restitution to VA of over $1.7 million.
Another VA OIG investigation resulted in charges alleging that the daughter of a deceased VA beneficiary continued to collect and withdraw her mother’s VA Dependency and Indemnity Compensation benefits following her mother’s death in November 2005. She was arrested after being charged in the Middle District of Florida with wire fraud. The loss to VA is approximately $338,000.
The OIG closed out fiscal year 2024 by publishing 31 reports in September. Topics include healthcare access and administration, financial efficiency, information technology, and facility inspections. I’ll highlight just two of these reports, which concern the electronic health record system, also known as EHR.
An OIG audit determined that VA and Oracle Health did not have adequate controls to prevent EHR system changes from causing major performance incidents, to respond to those incidents uniformly and thoroughly, or to mitigate their impact through standard procedures and interoperable downtime equipment. VA also had no formal process to link reports of patient care delays to specific major performance incidents. Ultimately, the inadequate controls stemmed from the initial May 2018 contract. In May 2023, VA modified the contract to strengthen some requirements but could do more.
Another report concerned OIG inspections of the VA Southern Oregon Healthcare System and the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington. During the inspections, leaders and staff at both facilities described notable concerns with the new EHR system related to efficiency and loss of productivity, staffing, financial impacts, and patient safety. Since 2020, the OIG has reported on various issues with the new EHR. The comments made by these leaders and staff demonstrate that new and previously identified issues persist.
Additional reports issued in September include healthcare facility inspections in Florida and New York as well as vet centers in Alaska, Oregon, Washington, California, Hawaii, Arizona, and New Mexico.
Thanks for listening. To read the entire September monthly highlights, go to the reports section of our website: www.vaoig.gov.
Fred Baker is a retired Army veteran and a career journalist. He has worked in government public affairs for the Army, the Department of Defense, and the VA Office of Inspector General.
Lauren O’Connor is a career writer-editor with the federal government. Here at the VA Office of Inspector General, she works to help veterans like her father, who graduated from the US Naval Academy and served on submarines before teaching at the Naval War College in Newport, Rhode Island.
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. Tune in monthly to hear how the VA OIG serves veterans, their families, and caregivers through meaningful independent oversight. 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 at vaoig.gov 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 988, press 1, and speak to a qualified responder now.