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
Trina, this is a somewhat difficult report to read, but I think it provides some valuable lessons that those in the VHA community can learn from. I hope that we can bring those out during this conversation. So first, let's talk about where this inspection took place.
Trina Rollins
This inspection was in Augusta, Georgia, the Charlie Norwood VA Medical Center—that's the parent facility. But it actually took place at a CBOC, community based outpatient clinic, in Aiken, South Carolina.
Fred Baker
And Aiken, I believe, is about 20 minutes away from Augusta.
Trina Rollins
Correct.
Fred Baker
What does an outpatient center do?
Trina Rollins
An outpatient center has usually primary care, mental health. They may do labs. They may have some imaging X-rays that can be done. But there's no inpatient care there. And most of our CBOCs or outpatient clinics will do just the routine appointment.
Fred Baker
And this outpatient center, is it a large outpatient center? Are they all about the same size?
Trina Rollins
This one had primary care, mental health. So, it was a probably a medium size if you take all of the clinics in VA. It had several services available.
Fred Baker
And before we move into this report, we've done work in Augusta previously, correct?
Trina Rollins
We have, and we've had several reports that actually pertained to this report. So, for our listeners, if you want to go to this published report and look, we'll reference those in the published report. But specifically, these reports were published in 2019 and 2020 and then again in 2022, which have recommendations that we call them repeat recommendations. The issue is still not fixed. Those other recommendations from the reports in 2019 and 2020 have been closed. So, to me that shows a difficulty in sustaining improvement. When you have a repeat finding, that means they had some type of action plan in place. They had some sustained improvement for a period of time, enough for us to close out the recommendation. But now, two to three years later, it's happening again or something similar is happening again.
Fred Baker
Right. In our previous work, one was based on a sentinel event, and the others were patient safety events. Can you kind of explain what those two are and the differences between them?
Trina Rollins
So, a sentinel event is a specific criteria. Joint Commission has that. VA has specific directives, policies that say, “This is what a sentinel event is, and this is how you must investigate it.” Patient safety events are more broad. It could be a death, similar to a sentinel event. But it could be more so that permanent or temporary harm was caused to a veteran. So again, there are events that happen that have caused something untoward for the veteran and possibly death. The sentinel event would be the more severe of a patient safety event.
Fred Baker
In all three of these reports, they were based on very serious implications to veteran care.
Trina Rollins
Correct.
Fred Baker
Let's move on to this investigation. How do we receive this hotline?
Trina Rollins
This hotline came to us a little differently. It was an unfortunate event in the fall of 2021, a building security guard at the Aiken CBOC actually discovered the veteran unresponsive on the grounds of the CBOC. So, in investigating that, the VA police would come in, take a look. They sent it to our OIG's investigative directorate. Since no criminal activity was confirmed, the investigators then turned it over to healthcare to review.
Fred Baker
And then you analyze it and decide whether or not we need to conduct an inspection.
Trina Rollins
Correct.
Fred Baker
What led you to decide, “Yes, this is an inspection. We should follow up on.”
Trina Rollins
What we normally do when we get a hotline complaint like this is actually go into the medical record. Review directives to see was there anything that we could find that was done incorrectly or were there missteps, missed opportunities? In this case, we took a quick look at the medical record, and we found several missed opportunities, which will be revealed later in the findings of the report. With our quick review, it was obvious that there were some missteps that we needed to take a look at.
Fred Baker
So, you launched the investigation. What is that process? Kind of walk me through those events.
Trina Rollins
When we open a hotline that we plan on publishing, we assign the team to it and that team is mostly healthcare inspectors, their supervisors, a director. We always have a physician on the team. We have an attorney advisor on the team. Those folks will develop a work plan and a list of documents they want to review. The documents could be directives from the VHA. It could be guidelines for practicing care. It could be Joint Commission standards. It could be occupational health and safety standards. So again, what we're looking at in this case was a suicide that occurred on the campus. So, we're looking at the medical record to determine what kind of mental and physical, medical care this patient had and did it contribute to him committing suicide.
Fred Baker
Is this work done here? Is it done in individual offices or do you go on location?
Trina Rollins
Our staff is located across the country, and they're usually not in the same office together. But when they we do a document request for VHA, we're getting those documents and putting them into a secure location where all of the staff on the team can access it. And so, they're reviewing that, checking those, and that's how they develop questions for investigation. They will then do a site visit. In this case they wanted to see the location, the CBOC or the clinic location, and then interview staff that had direct care with this patient as well as the leadership at the facility and at the clinic.
Fred Baker
How long does it take to draft a report like this?
Trina Rollins
Usually, four to five months. It's a long process because, again, we want to make sure that we're being thorough with our investigation, that we're looking down all avenues to ensure that the information that we have is . The team will work usually four to five months gathering information, doing the interviews, and then drafting the report.
Fred Baker
This investigation—really you found there was not one person or one misstep at fault, but there were several missteps, as you spoke to earlier by staff at several points.
Trina Rollins
Unfortunately, yes.
Fred Baker
Can you kind of walk us through the timeline?
Trina Rollins
Sure. I won't go through all of the details in his medical record. The listeners can review that in the published report, but through the findings, there were many staff whose actions or inactions actually delayed the care for this patient. The veteran actually initiated care with the VA in spring of 2021, meaning he had his intake appointment. His first appointment with the primary care provider. At that appointment, he had positive mental health screens, meaning–the VA has clinical reminders where we're doing screenings for depression. We're doing screenings for alcohol use, drug use, those types of things that are supposed to then alert staff providers of whether or not further consults or further care should be initiated. He had positive mental screens, but actually declined further mental healthcare at that appointment.
Fred Baker
When you say these positive screens for depression, for alcohol misuse, in the mention of suicidal ideation, those should have been flagged somehow in his record?
Trina Rollins
They were flagged in his record. And the next step would have been consults to mental health to help address these issues. At this point in time, his first appointment, the veteran actually declined to go to those appointments. So, the provider did not place those consults.
Fred Baker
Okay.
Trina Rollins
That’s correct. The patient has a right to refuse care. So, a couple of weeks later, he comes in. Unfortunately sees another provider, and that provider failed to follow up on those positive screens. So, again, what should have happened is you asked the patient again about his mental health. He had a positive depression screen. He had mentioned suicidal ideation at the previous appointment, and you would want to see a follow-up, a checking in on the patient to see how he's doing. But that was not done.
Fred Baker
So why didn't they do it?
Trina Rollins
They were concerned with his pain care.
Fred Baker
So, at this point, he was there for pain?
Trina Rollins
He was there for pain at the first appointment. That was one of his main complaints, and then he was complaining of pain at the second appointment, too.
Fred Baker
OK, great. So, the first point he went for pain, they identified these three. . .
Trina Rollins
Through the screenings, identified other issues. At this appointment he did explain that the pain was severe enough that it was causing him to have thoughts of wanting to harm himself. So again, that triggered the reminder and triggered the first primary care provider to ask him, “Would you like to me to make some consults or appointments for you in mental health,” which he declined.
Fred Baker
So, goes back a second time.
Trina Rollins
Goes back a second time. The second provider is addressing his pain by putting in a pain consult. But didn't make the correlation of depression, suicidal ideation also contributes to pain.
Fred Baker
Right. So, what happens next?
Trina Rollins
Then, a few weeks later, he comes in again for pain issues and sees a third primary care provider. That provider actually did place a mental health consult, but that mental health consult was discontinued after the psychiatrist reviewed it because the psychiatrist recommended that additional testing be done. The primary care providers thought the patient had a psychiatric disorder, and he may have; but additional testing was needed before the psychiatrist could make any type of determination. When the consult was discontinued, that provider ordered additional testing, but not the test that the psychiatrist recommended, that would have helped you know to determine whether or not this patient had this specific psychiatric disorder. And when asked, those providers were like, “I didn't really know about that test. I don't have a good understanding, so I couldn't tell you why I didn't order it.”
Fred Baker
But he just didn't order.
Trina Rollins
Just didn't do it.
Fred Baker
And so finally, the next step.
Trina Rollins
The next step—the pain consult had been placed by the second primary care provider, but it was not addressed timely. This patient wasn't scheduled for an appointment for 139 days, 4 1/2 months. It took for him to get an appointment in pain management clinic. And the provider who placed the console did think the veteran would do better using VA care for pain management, but he—meaning the veteran—wasn't even offered community care by anyone. Per VA policy, if the appointment can't be made within VA timely, usually within 30 days, they should be referred to community care or at least offered community care. Then the veteran has the opportunity to say, “No. I want to stay within VA. I'll wait for the appointment.” But he wasn't offered.
Fred Baker
So, he had to wait 4 1/2 months for his first pain management clinic.
Trina Rollins
Correct.
Fred Baker
All the while . . .
Trina Rollins
Being in pain.
Fred Baker
Being in pain.
Trina Rollins
And again, being depressed and having suicidal thoughts.
Fred Baker
Did they give a reason why they didn't offer him community care?
Trina Rollins
They said it was a missed opportunity. The scheduling clerk should have, but didn't.
Fred Baker
It sounds like he's meeting at least three different providers, right? Why was he meeting different providers through this process? Why not the same one?
Trina Rollins
That's a good. question because, again, in VA you're assigned a primary care provider called your PCP, that, in theory, should be the main provider you see. That's where all of your referrals start for specialty care, and that's how you gain continuity of care. Unfortunately, with this veteran, he saw one provider, and then the next appointment saw a different provider, and then the third appointment saw a third provider. Some of the reasons why that could happen is maybe the provider had called in sick and someone was covering the clinic for that person. Or that person may have left the VA. So again, another provider had taken over those patients until a new provider could come in and be hired.
Fred Baker
So, he finally got his appointment. Did he get to make that appointment?
Trina Rollins
Yes, he did get that appointment in the summer of 2021. He began care early in the spring and didn't get the appointment until summer. But at that appointment, the pain management clinic providers didn't do what they were supposed to do. In pain management clinic, you should be screened for suicide, depression, those types of things. It's actually called a Columbia Suicide Severity rating score. They should have that screening done if the pain appointment is greater than 30 days from when the referral took place. And remember this was 139 days later, and it should be done at every initial appointment. This was the first time they saw this patient, so he should have had that done just because it was an initial appointment. But it also should have been done because it was greater than 30 days after the referral took place.
Fred Baker
So, do you know that he finally got his pain addressed?
Trina Rollins
They started addressing his pain. Unfortunately, pain management is a very complex specialty. In this case, they needed to try and find out what the cause of this pain was in order to treat it appropriately. In the meantime, the patient was still depressed, still having suicidal thoughts, and actually made a call to the Veterans Crisis Line expressing that his pain was severe, chronic, and causing him suicidal thoughts. The VCL responder felt the patient needed urgent care. They felt that the veteran needed urgent referral for evaluation and so contracted with the veteran, meaning verbally contracted, that the veteran would take a referral from them to the emergency room and go and be seen. This veteran agreed to be seen in the emergency room. So, he's traveling to the emergency room, the Veterans Crisis Line responder calls the emergency room at Augusta to let them know this patient is on his way and that he's suicidal, he's been having suicidal thoughts, and he's had chronic pain that's contributed to this. The VCL responder spoke to a nurse. Unfortunately, that nurse didn't tell any of the providers working in the emergency room that day. So, when the patient shows up, he waited, was routinely triaged for care, and when he saw the emergency provider, told him about his pain but didn't mention the suicidal ideation or depression, which is not that unusual. Again, you're not going to admit that. Most of the time you have to be asked those questions to admit it.
Fred Baker
Before we move on, why didn't the nurse let the provider know about the Veterans Crisis Line call?
Trina Rollins
At this point in time, when this occurred, there was no requirement for documentation of the Veterans Crisis Line respond calling and giving the heads up to the staff. The nurse did not have a clear answer why she didn't contact one of the emergency providers. It was again another missed opportunity to help this veteran.
Fred Baker
So, the nurse didn't tell the provider. The provider didn't know. The veteran didn't tell the provider.
Trina Rollins
Exactly. And then when we spoke to the provider, the provider admitted, “If I had known this gentleman had suicidal thoughts, then I would be firstly directing him for mental healthcare.” But unfortunately, this patient was discharged home.
Fred Baker
And what happened with the follow up from the Veterans Crisis line? They're required to follow up on the call.
Trina Rollins
Exactly. When a veteran makes a call to the Veterans Crisis Line, the responder there will make a consult for suicide prevention coordinators to contact the patient. That contact is made through a system specific to VCL.
Fred Baker
Just so we're clear, the Veterans Crisis Line contacts a local suicide provider.
Trina Collins
Correct. Suicide prevention coordinator.
Fred Baker
So, this would have been someone . . .
Trina Rollins
At the facility.
Fred Baker
Either at the center or at the VA medical center. One or the other.
Trina Rollins
Exactly. At the Medical Center.
Fred Baker
OK, so it would have been local.
Train Rollins
Exactly
Fred Baker
OK. Go ahead. I'm sorry.
Trina Rollins
When that happens, the consult is sent and a suicide prevention coordinator program person is supposed to contact the veteran to ensure that, in this case, he went to the emergency room, got care. Actually, in this case, the VCL responder had mentioned, “I think this veteran needs mental health and primary care follow-up as well,” so recommended additional appointments for this veteran, which did not occur either. The problem with this case is that the suicide prevention staff didn't follow up. They documented that the patient had, “follow-up,” but they were referencing the follow-up that the emergency provider provided to the veteran. So, it's a loophole. It's a loophole that we've we noticed in one of our previous a national report on this and recommended to the USH to close that.
Fred Baker
To the who?
Trina Rollins
The Under Secretary for Health in the VA, to help close that loophole. The loophole is . . .
Fred Baker
So, they referenced . . .
Trina Rollins
Someone else making contact.
Fred Baker
The emergency care providers care as a contact, even though that provider did not know anything about the call to the Veterans Crisis Line.
Trina Rollins
Exactly. The suicide prevention coordinator—suicide prevention case manager did not contact the veteran directly. And then didn't follow up on the recommendation for additional appointments either. The veteran didn't get contact from a suicide prevention case manager and didn't get those additional appointments that the VCL responder felt he needed.
Fred Baker
Can you help me understand why a suicide prevention coordinator would think like that? Would not follow up with you?
Trina Rollins
Again, it was a misinterpretation of the policy, which is addressed in the report. Suicide prevention coordinators need improved training, guidance, and oversight. It was a report that we published back in June of 2022. And again, what we recommended was that there be better oversight of this contact. It was interpreted that if anyone made contact, anyone at the VA made contact, then the patient was “contacted” in reference to the VCL consult. But unfortunately, an emergency department provider who didn't have a clear understanding of this patient being suicidal, having depression, wasn't the appropriate person to make that contact. What we've recommended in that report was to close those gaps. We have been told that there has been some change in the policy locally as well, so that, it is a requirement for the suicide prevention Coordinator now to make direct contact him or herself.
Fred Baker
In this event, we're back to the fall morning, and the veteran was found dead, unfortunately. What happened next?
Trina Rollins
What should happen next is there should be some type of internal review to find what happened. Why did this happen? Were there any circumstances that could have prevented this from happening? The first thing we noticed was the facility initiated a clinical review, meaning they took a look at his actual care, medical care. They did not identify any issues. We've already gone through several missed opportunities, just us talking in this podcast; but those weren't brought up in the internal clinical review that the facility did. They didn't mention the long wait time. They didn't mention the missed follow-up by the suicide prevention case manager. They didn't mention the screening that should have taken place, the suicide screening that should have taken place at pain management clinic. So again, we felt there were some gaps in that review.
Fred Baker
If you discovered all of these missteps clearly, how come they missed them?
Trina Rollins
So, I think part of the issue is that the clinical review was done by the service chief, meaning it stayed within the department, whether it be pain management, mental health, primary care, and they didn't use input from quality management and patient safety. Those departments are specifically, have the expertise to do these types of quality reviews to help find what opportunities were missed, what system problems occurred that may have contributed to his death. So, unfortunately, they didn't use that expertise. and I think they missed the mark on this specific review.
Fred Baker
In addition to the clinical review, they initiated another review as well, correct?
Trina Rollins
Correct. An administrative review. It's called a root cause analysis, an RCA. RCAs are meant to find or are meant to investigate problems and look for the root cause of those problems. In this case, the director initiated the RCA and put together a team. But unfortunately, that team didn't align with the requirements for VHA. The team should be unbiased. They shouldn't have direct care—they shouldn't have provided direct care to this patient. We need people on the RCA that can be objective. When the director made the first team, he had members of that team that would have had direct care, or at least there was a conflict of interest for that person. The director then chartered a second team and made the same mistake again—had again people on the team that would have conflicted with VHA guidance for that team. It took three times before the composition, just that the people on the RCA team, met the VHA requirements for policy for RCAs.
So, they ended up completing some quality management reviews, but again, these didn't follow policy as well. A behavioral health autopsy must be done after every veteran suicide. That's part of the policy. But this one contains some errors. Another requirement is to do a family interview tool contact, meaning they contact the veteran’s family to ask questions, to again try and find reasons or determining factors of why this veteran completed suicide. But staff said they couldn't find any family to contact, but again when OIG looked in the medical records or documents pertaining to this veteran, two family members were identified.
And then finally, the facility leaders should have done peer reviews on these providers, especially the ones that we pointed out that missed opportunities. Those did not start until OIG requested the results of the peer reviews.
Fred Baker
It's clear in this inspection that this veteran was not treated to the level that they should have been treated and there were many missteps along the way. Which is again a very sad and unfortunate event.
Trina Rollins
Very unfortunate.
Fred Baker
What were the recommendations we made?
Trina Rollins
We made nine recommendations to the facility director. They are related to mental health screenings, consult management, referrals to community care, mandatory suicide risk assessments, communication of VCL referral information to emergency department providers, staff documentation and closure of VCL referrals, completed suicides on VA campuses, accurate completion of behavioral health autopsy, and the family interview tool contact forms, as well as peer reviews and clinical reviews. As you've heard throughout this podcast, those are all of the findings that we hit on.
Fred Baker
Those sound very administrative. What is the crux? If you were to roll all of these recommendations up into one sentence, what are we asking them to do?
Trina Rollins
Well, it is administrative, but the reason VA puts these administrative policies guidelines in place is because they have been shown to improve patient care.
Fred Baker
So, what was the response? How did VA respond to these recommendations?
Trina Rollins
They concurred with the recommendations. This was a difficult report to discuss with VHA. They had already made some changes because, again, it takes us time to get through our editing process and, in that time, VHA was already, the facility was already working on improving or making improvements to some of these issues that we brought up. They did concur with all of our recommendations. They had initially requested that three of our recommendations be closed at the time of publication, but we kept them open just to allow the facility time to submit actual documentation that support that the actions had been completed. Some of these actions will need monitoring. We’ll be looking at three, six, nine months’ worth of data to make sure that there is sustained improvement with some of these actions and hopefully the VA will continue to learn from these recommendations and make improvements.
Fred Baker
Are we hopeful that with this monitoring that they'll be able to sustain this level of improvement?
Trina Rollins
Yes, we're always hopeful. Again, with this, we've got the network director, the VISN 7 network director is in concurrence. VISN should be monitoring this as well, and with the “loophole” that I mentioned previously on the documentation for the VCL response, the under secretary for health should be addressing that. But again, in this case, the facility has gone ahead and addressed it at a local level, so they're retraining staff with the understanding that they must make that initial contact themselves.
Fred Baker
Some positive moves already.
Trina Rollins
Definitely, definitely.
Fred Baker
Great. Trina, any other thoughts?
Trina Rollins
No, that's it. I hope our listeners will definitely access the report and read through it. The team took a lot of time to make sure they got all the facts in this, and we want to encourage everyone to read our reports just to ensure that we are doing our job. You know, our job of oversight.
Fred Baker
Well, thank you again, and I look forward to having you on the podcast soon.
Trina Rollins
Thank you.
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 cohost Mary, and she'll provide the updates from our most recent oversight work.
Mary Estacion
Thanks Fred. The VA OIG had a busy June on the Hill, testifying three times on VA care coordination, substance use disorder treatment programs in rural areas, and the status of several of VA’s financial management systems.
First, let’s talk about Dr. Julie Kroviak’s testimony on June 13 before the House Committee on Veterans’ Affairs Subcommittee on Health. She’s the Principal Deputy Assistant Inspector General for Healthcare Inspections. Her testimony focused on numerous OIG healthcare inspection reports that identified deficiencies in VA care coordination. She specifically pointed out that patients transitioning between levels of care and among service lines (which are specific areas of clinical care such as cardiology or oncology) are at the most risk. In response to questions, Dr. Kroviak discussed the challenges in coordinating care for veterans when community care providers do not promptly return medical records to the Veterans Health Administration or VHA.
On June 14, Dr. Kroviak made a return visit to the Hill, but this time she testified before the Senate Veterans’ Affairs Committee to convey VHA’s challenges in effectively meeting the needs of individuals with substance use disorders, especially within rural settings. She stressed that VA should improve its collaboration with third-party administrators and community care providers for high-risk veterans with complex mental health conditions. Dr. Kroviak answered questions about VA’s opioid-prescribing practices and the risks to patients when community care providers do not share appointment data and electronic health records with VA providers in a timely manner.
Nicholas Dahl, the VA OIG’s Deputy Assistant Inspector General for Audits and Evaluations, testified on June 20 before the House Veterans’ Affairs Subcommittee on Technology Modernization. His testimony spotlighted the findings and recommendations of several OIG oversight reports that examined VA’s financial management systems. He discussed the vulnerabilities and deficiencies VA encounters due to a significantly outdated system, the benefits of a modern system, and how VA might improve its deployment of a new system. In response to questions, Mr. Dahl explained the findings in numerous OIG reviews of failed information technology system implementations at VA.
For more details on these hearings, you can check out the VA OIG website for the written congressional statements and recordings of opening statements. For videos of entire testimonies at the hearings, you can check out the congressional committees’ websites.
The VA OIG participated in a multiagency investigation that resulted in charges alleging that three executives of a healthcare software and service company conspired to use telemarketers to reach out to targeted individuals—including Medicare, TRICARE, and CHAMPVA beneficiaries. The company executives were also charged with generating standardized orders for medically unnecessary orthotic braces and pain creams and then getting doctors to sign the orders in exchange for kickbacks and bribes. The VA, Medicaid, and other sources paid those executives for the improperly prescribed devices and creams. The total loss to the government is $2.8 billion, including a more than $1 million loss to VA. The defendants were indicted in the Southern District of Florida. This investigation was conducted by the VA OIG, the Defense Criminal Investigative Service, the FBI, and the Department of Health and Human Services OIG.
A VA OIG investigation on education benefits fraud revealed that the chief executive officer of a non-college-degree-granting technical school admitted to his role in the largest known incident of Post-9/11 GI Bill benefits fraud prosecuted by the Department of Justice. The defendant and multiple co-conspirators defrauded the benefits program by falsifying attendance records, student grades, and professional certifications to conceal they were not complying with VA’s “85/15” rule. This rule is intended to ensure VA is paying fair market value tuition by requiring that at least 15 percent of enrolled students pay the same rate with non-VA funds. In addition to falsifying records and allowing students to complete coursework online at their own pace, the co-conspirators posed as students when contacted by the state approving agency to confirm graduation and job placement. The chief executive officer was sentenced in the District of Columbia to five years in prison, three years of supervised release, and restitution to VA of almost $105-million dollars.
The VA OIG regularly publishes fraud alerts. Visit our website to view the alert on stopping Education Benefits Fraud. Please report any VA-approved school that is billing veterans (whose enrollment is funded by VA) a higher tuition rate than civilian students for the same courses. VA-approved schools that engage in education benefits fraud often advertise a lower tuition rate than they are billing VA for veteran student enrollments; offer discounts, tuition waivers, or scholarships exclusively to civilian students; or bill at least 20 percent more than non-VA-approved schools with similar course offerings.
And finally, the Offices of Inspector General from the VA and the Department of Housing and Urban Development (or HUD) teamed up to investigate allegations that a mortgage lender failed to comply with program requirements when it originated and underwrote mortgages guaranteed by VA or insured by HUD’s Federal Housing Administration. The requirements included maintaining quality control programs to prevent and correct underwriting deficiencies, self-reporting any materially deficient loans that they identify, and ensuring that the underwriting process is free from conflicts of interest. The lender entered into a civil settlement agreement under which it agreed to pay more than $23.7 million to resolve False Claims Act allegations. Of this amount, VA will receive more than $8 million dollars.
The OIG issued a pair of financial efficiency reports this month. The first one involved the VA New York Harbor Healthcare System, specifically assessing open obligations, purchase card use, inventory and supply, and pharmacy operations. The inspection team could not verify that inactive obligations were reviewed and found unreconciled open obligations more than three months old. Purchase card holders did not always obtain prior approval for purchases or perform required reconciliations, and the team estimated that noncompliance errors led to about $44.1 million in questioned costs. Pharmacy deficiencies included observed drug costs higher than expected, turnover rates below recommended levels, a noncompliant inventory process, and inadequate reconciliation reporting. The healthcare system director concurred with the OIG’s 14 recommendations, which included ensuring staff review open obligations and pharmacy reconciliations, update usage data and use the prime vendor.
The OIG’s second financial efficiency inspection report released this month assessed the VA Philadelphia Healthcare System. Inspectors found several opportunities to improve oversight and ensure the appropriate use of funds. The VA OIG found approximately 18,500 purchase transactions with potential noncompliance errors, leading to about $16 million in questioned costs. The healthcare system could also ensure stock levels and inventory values are recorded correctly, as well as improve the efficiency of its pharmacy by narrowing the gap between observed and expected drug costs, avoiding end-of-year purchases, and meeting requirements for monthly reconciliation reporting. VA concurred with the OIG’s 12 recommendations made to the healthcare system director to improve these processes, encourage greater cost efficiencies, and promote the responsible use of VA’s appropriated funds.
The VA OIG published a national review evaluating the transition of clinical care from the Department of Defense to VHA for service members with opioid use disorder or OUD. Failure to document OUD history may decrease the likelihood of future providers using medically relevant information and may put patients at risk for adverse outcomes. The OIG conducted electronic health record reviews for two groups identified from a sample of discharged service members with an OUD diagnosis: patients without an OUD diagnosis in VHA data and patients who experienced an opioid-related death.
Deficiencies were found in VHA primary care and mental health providers’ documentation identifying the opioid use disorder in encounters, progress notes, and problem lists for both groups—despite having a diagnosis of OUD in DoD treatment records. The OIG made five recommendations to the VA under secretary for health related to the identification of barriers for providers documenting OUD in electronic health records; training on the use, navigation, and retrieval of DoD treatment record information; evaluation of the barriers to access and use of DoD treatment records; and evaluating and updating processes to the identification of patients with opioid use disorder.
I’ll wrap up this month’s highlights with new Comprehensive Healthcare Inspection Program or CHIP reports. They are part 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 following facilities: VA North Texas Health Care System in Dallas; New Mexico VA Health Care System in Albuquerque; Manila VA Clinic in Pasay City, Philippines; Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network in Arlington; VA Southern Nevada Healthcare System in North Las Vegas; and Phoenix VA Health Care System in Arizona.
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.”
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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.