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 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 health care system and give us a little context?

Trina Rollins
Sure. The Carl Hayden VA Medical Center is the VA in Phoenix. It has ten associated outpatient clinics and as part of VISN 22. It is a 1A high-complexity-rated facility within VA and provides health care 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 of 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 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 paid 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 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 in 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 non-cancerous, 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 these purposes.

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, a picture. So that’s, you know, is it 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. Sure. 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? Is it?

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.”

Trina Rollins
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 to 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, four hundred, 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 would 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, 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 sent out a letter explaining to the veterans what happened and that they 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
Couple, Yeah.

Trina Rollins
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 was prepaid, had a preprinted label on it, so it had the patient’s name and, you know, the appropriate ID 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 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 facilities’ 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 and 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?

Trina Rollins
Yes, 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 assessing of the test and processing it. And then they also passed all of that information to all of the other facilities within VISN 22. So, it wasn’t just Phoenix, you know, they made sure all of the facilities in VISN 22 had the same information and the same knowledge. So, to follow that up, they’re doing weekly audits and checking to make sure that the logging process is being done correctly. And so far, the reported compliance has been 100 percent.

Fred Baker
Did we have any other recommendations?

Trina Rollins
We did. We had some recommendations for the facility and 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 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 a 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 to VHA as a whole, they co-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 Rollins
You know, 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 at www.va.gov/oig/hotline and fill out 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 nine, eight, eight and then press one. Now let's go to Lauren for the highlights of our oversight work for this past month.

Lauren O’Connor
Thanks, Fred.

In January, our Principal Deputy Assistant Inspector General for Healthcare Inspections, Dr. Julie Kroviak, testified before the Senate Committee on Veterans’ Affairs. Her testimony focused on repeated deficiencies identified by the OIG’s proactive Vet Center Inspection Program. Vet centers are community-based counseling centers providing a wide range of social and psychological services to eligible veterans, service members, and their families to support a successful transition from military to civilian life. Dr. Kroviak lauded the dedication of vet center staff while recognizing that the limited progress by these centers over the last three years—particularly for suicide prevention activities—suggests that barriers remain in improving and sustaining compliance with critical VA policies. She called for stronger leadership engagement and continuous oversight of the staffs’ daily activities, particularly when working with veterans at high risk for suicide. In response to questions, Dr. Kroviak suggested that vet center directors would benefit from reviewing all of the OIG’s Vet Center Inspection Program reports and that focusing on clear and consistent communication with VA medical centers would help improve vet center performance and outcomes. Check out the OIG’s website for written statements and recordings of opening statements for all OIG congressional testimony.

Meanwhile, the Office of Investigations had several investigative updates in January.

An investigation by the VA OIG and Michigan attorney general found that three individuals used aliases to obtain or create fraudulent documents, including vital records such as birth certificates, to make it appear as if they were the surviving spouses of deceased veterans. These documents were used to fraudulently obtain VA Dependency and Indemnity Compensation benefits, VA Survivors Pension benefits, and unclaimed funds from Michigan. One of the three individuals pleaded no contest to conducting a criminal enterprise and false pretenses for defrauding VA and the Michigan Department of Treasury. Pursuant to the plea agreement, the defendant will be sentenced to serve between six and a half to 20 years of incarceration and be ordered to pay $470,000 in restitution. Of this amount, VA is due to receive $430,000.
In a different case, an individual received VA Dependency and Indemnity Compensation benefits intended for his grandmother due to both her husband’s and son’s military service. A review of the grandmother’s bank records revealed that for nearly 30 years, the grandson used her VA benefits for his own personal expenses after she passed away in November 1993. The loss to VA is more than $340,000. Following an investigation by the VA OIG, the grandson was sentenced in the Western District of Missouri to 12 months of home confinement, five years of probation, and over $340,000 in restitution after previously pleading guilty to theft of government property.

In January, the VA OIG published 16 reports. I’ll highlight a few of them now.

From the Office of Audits and Evaluations comes a report titled VA Should Enhance Its Oversight to Improve the Accessibility of Websites and Information Technology Systems for Individuals with Disabilities. VA is required by law to make information on its websites, related resources, and data systems accessible to people with disabilities. The OIG conducted this audit to address concerns from Congress and a veterans service organization about the accessibility of VA websites and information technology systems. The OIG found areas where VA’s efforts and monitoring of Section 508 requirements could be improved to ensure websites and information technology systems are equally accessible to all. Specifically, web managers did not routinely maintain the Web Registry, VA’s official repository of websites, as required, and websites were not consistently scanned for compliance until recently.

VA officials also did not always keep administrations and staff offices apprised of requirements and related procedures, resulting in noncompliant VA information technology systems and an inaccurate VA Systems Inventory, which designates systems as Section 508 compliant, noncompliant, or unassessed. Finally, three directives were not recertified within the required timeline. The OIG made six recommendations to address these shortcomings and safeguard accessibility.

The VA OIG’s Office of Healthcare Inspections reviewed national and healthcare system guidance issued by VHA regarding the inpatient management of alcohol withdrawal. Determining a patient’s severity of alcohol withdrawal is critical in facilitating treatment decisions that may prevent the progression of symptoms that could be fatal. Current VHA guidance does not specifically address inpatient management of alcohol withdrawal, which does not fall under a single VHA national program office. The OIG found healthcare systems lacked written guidance related to assessing alcohol withdrawal severity; determining the appropriate level of care; evaluating co-occurring conditions; consulting with substance use disorder experts; and administering drug therapy interventions.

VA’s under secretary for health concurred with the OIG’s three recommendations to identify a national program office for the oversight of alcohol withdrawal management in inpatient settings; to develop written guidance that includes expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; and to implement related training for inpatient staff.

The VA OIG published management advisory memoranda on monthly housing allowances for veterans, VA’s initial allocation of toxic exposures funds, and concerns with using VA’s new financial and acquisition management system known as iFAMs.

We also published seven Comprehensive Healthcare Inspection Program reports focused on VA medical facilities in Indiana, Florida, Delaware, Wisconsin, California, South Carolina, and Puerto Rico. To read these reports, visit our website at vaoig.gov and select the reports tab.
I’ll wrap up January’s highlights with a featured hotline case, which substantiated allegations of resident abuse and a hostile work environment at the Tucson VA Medical Center’s Community Living Center. The OIG Hotline received allegations that residents of the center were subjected to systemic verbal and physical abuse by VA staff and contractors, and a hostile work environment prevented some staff from reporting the abuse that could have helped to protect residents. The allegations and supporting evidence were sent to VISN 22—the Desert Pacific Healthcare Network—for review and response. Following staff interviews and a review of records, witness statements, and VA police reports, a VISN team substantiated that verbal abuse and unprofessional conduct had occurred, and that a hostile work environment did prevent some staff from raising concerns about residents.

The team recommended 14 corrective actions for the medical center director to review, implement, and monitor. The corrective actions included establishing an orientation and continuing training program for center staff and retraining managers on responding to and addressing concerns of resident abuse, unprofessional conduct, and bullying in the workplace.

Thank you for listening to January’s highlights. Visit our website for all VA OIG podcast episodes.

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 or call the hotline at 1-800-488-8244.