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Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System

August 26, 2014 Comments off

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General

This is the final report addressing allegations of gross mismanagement of VA resources, criminal misconduct by senior leadership, systemic patient safety issues, and possible wrongful deaths at the Phoenix VA Health Care System. The OIG found patients at the Phoenix VA Health Care System experienced access barriers that adversely affected the quality of primary and specialty care provided for them. Patients frequently encountered obstacles when patients or their providers attempted to establish care, when they needed outpatient appointments after hospitalizations or emergency department visits, and when seeking care while traveling or temporarily living in Phoenix.

In February 2014, a whistleblower alleged that 40 veterans died waiting for an appointment but the whistleblower did not provide us with a list of 40 patient names. However, we conducted a broader review of 3,409 veteran patients identified from multiple sources, including the electronic wait list, various paper wait lists, the OIG Hotline, the U.S. House Veterans Affairs Committee and other congressional sources, and media reports. We were unable to assert that the absence of timely quality care caused the deaths of these veterans.

This report includes case reviews of 45 patients who experienced unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care. The patients discussed reflect both patients who were negatively impacted by care delays (28 patients including 6 deaths), as well as patients whose care deviated from the expected standard independent of delays (17 patients including 14 deaths). In addition to 1,400 veterans waiting to receive a scheduled primary care appointment who were appropriately included on the Phoenix VA Health Care System Electronic Wait List, we identified over 3,500 additional veterans. Many of the 3,500 veterans were on what we determined to be unofficial wait lists and were at risk of never obtaining their requested or necessary appointments.

Since the Phoenix VA Health Care System story first appeared in the national media, the OIG received approximately 225 allegations regarding health care at Phoenix and approximately 445 allegations regarding manipulated wait times at other VA medical facilities. The VA OIG Office of Investigations opened investigations at 93 sites of care in response to allegations of wait time manipulations. We are coordinating our investigations with the Department of Justice and the Federal Bureau of Investigation.

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DoD and VA Take New Steps to Support the Mental Health Needs of Service Members and Veterans

August 26, 2014 Comments off

DoD and VA Take New Steps to Support the Mental Health Needs of Service Members and Veterans (PDF)
Source: U.S. Department of Defense/U.S. Department of Veterans Affairs

Today, President Obama will announce 19 new executive actions that the Departments of Veterans Affairs (VA) and Defense (DoD) are taking to improve the mental health of service members, veterans and their families. Today’s announcement builds on the actions the Departments have taken in response to the President’s 2012 Executive Order on service members, veterans and their families’ mental health. In response to the Executive Order, VA has increased its mental health staffing, expanded the capacity of the Veterans Crisis Line, and enhanced its partnerships with community mental health providers. DoD is reviewing its mental health outreach programs to prioritize those with the greatest impact; DoD and VA worked to increase suicide prevention awareness and, DoD, VA and the National Institutes of Health jointly developed the National Research Action Plan on military and veteran’s mental health to better coordinate federal research efforts. These efforts and actions represent the latest in DoD and the VA’s continued commitment to ensure that this Administration is working to fulfill our promise s to service members, veterans and their families, and we will continue to look for additional ways to do so in this space, both thorough our work and work with the private sector.

Combined Assessment Program Summary Report: Evaluation of Hospice and Palliative Care in Veterans Health Administration Facilities

August 12, 2014 Comments off

Combined Assessment Program Summary Report: Evaluation of Hospice and Palliative Care in Veterans Health Administration Facilities (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General

The VA Office of Inspector General Office of Healthcare Inspections completed an evaluation of hospice and palliative care in Veterans Health Administration facilities. The purposes of the evaluation were to determine whether VHA facilities performed active hospice and palliative care case finding, provided end-of-life care training to staff, and met selected documentation standards and to assess selected Palliative Care Consult Team processes, documentation, and staffing.

Inspectors evaluated hospice and palliative care at 54 facilities during Combined Assessment Program reviews conducted from October 1, 2012, through September 30, 2013.

Although we observed many positive practices, we identified two opportunities for Veterans Health Administration facilities to improve. We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that:

+ Facilities provide at least the minimum required Palliative Care Consult Team staffing.

+ Facilities provide end-of-life care training to staff who work in areas where they are likely to encounter patients at the end of their lives.

VA OIG — Administrative Investigation, Prohibited Personnel Practice and Preferential Treatment, National Cemetery Administration, VA Central Office

July 22, 2014 Comments off

Administrative Investigation, Prohibited Personnel Practice and Preferential Treatment, National Cemetery Administration, VA Central Office (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General

The former Under Secretary for Memorial Affairs engaged in a prohibited personnel practice when he created a position and preselected an employee for that position. He also engaged in preferential treatment of an NCA contractor when he developed a less-than-arm’s-length relationship with the contractor. Further, NCA improperly gave the contractor sole-source contracts to provide one-to-one services to select NCA employees.

VA OIG — Review of the Special Initiative To Process Rating Claims Pending Over 2 Years

July 15, 2014 Comments off

Review of the Special Initiative To Process Rating Claims Pending Over 2 Years (PDF)
Source: U.S. Department of Veterans Affairs, Office of Inspector General

On April 19, 2013, the Veterans Benefits Administration (VBA) began a Special Initiative to process all claims pending over 2 years. VA Regional Office (VARO) staff were to issue provisional ratings for cases awaiting required evidence and complete these older claims within 60 days. Our review focused on whether (1) provisional ratings resulted in veterans receiving benefits more quickly and helped eliminate the backlog, and (2) older claims were accurately. The Special Initiative rating process was less effective than VBA’s existing rating process in providing benefits to veterans quickly. Further, VBA removed all provisional claims from its pending inventory, despite more work being needed to complete them. This process misrepresented VBA’s actual workload of pending claims and its progress toward eliminating the overall claims backlog. At the end of June 2013 following completion of the Special Initiative, VBA reported 516,922 rating claims pending in its backlog, but only 1,258 rating claims pending over 2 years. We estimated 7,823 provisionally rated claims had been removed from the inventory though they still awaited final decisions. These claims represented less than 2 percent of VBA’s reported backlog, but about 12 percent of claims completed under the Initiative. VAROs did not prioritize finalization of the provisionally rated claims once they were issued. We estimated 6,860 provisional ratings were still waiting for final decisions as of January 2014, 6 months after the Initiative had ended. Because VBA did not ensure existing controls were functioning as needed to effectively identify and manage provisionally rated claims, some veterans may never have received final rating decisions if not for our review. Additionally, VBA did not accurately process 77 (32 percent) of 240 rating decisions we reviewed under this Initiative. Generally, these errors occurred because VAROs felt pressured to complete these claims within VBA’s 60 day deadline. We estimated VARO staff inaccurately processed 17,600 of 56,500 claims, resulting in $40.4 million in improper payments during the Initiative period. We recommended the Under Secretary for Benefits establish controls for all provisionally-rated claims, reflect these claims in VBA’s pending workload statistics, expedite finalization of provisional ratings, and review for accuracy all claims that received provisional ratings under the Special Initiative. The Under Secretary for Benefits concurred with our recommendations. Management’s planned actions are responsive and we will follow up as required on all actions.

No Time to Waste: Evidence-Based Treatment for Drug Dependence at the United States Veterans Administration Department of Veterans Affairs

July 13, 2014 Comments off

No Time to Waste: Evidence-Based Treatment for Drug Dependence at the United States Veterans Administration Department of Veterans Affairs
Source: Human Rights Watch

The 39-page report states that more than one million US veterans take prescription opioids for pain, and nearly half of them use the drugs “chronically,” or beyond 90 days. Alcohol and drug dependence is strongly associated with homelessness and mental health conditions including post-traumatic stress syndrome and depression, psychological conditions that affect 40 percent of Iraq and Afghanistan veterans in VA care. Drugs or alcohol are involved in 1 of 3 Army suicides, and the VA estimates that 22 veterans commit suicide each day.

Beyond the Waiting Lists, New Senate Report Reveals a Culture of Crime, Cover-Up and Coercion within the VA

June 24, 2014 Comments off

Beyond the Waiting Lists, New Senate Report Reveals a Culture of Crime, Cover-Up and Coercion within the VA
Source: U.S. Senator Tom Coburn (R-OK)

U.S. Senator and doctor Tom Coburn, M.D. (R-OK), today released his new oversight report “Friendly Fire: Death, Delay, and Dismay at the VA.” The report is based on a year-long investigation of VA hospitals around the nation that chronicled the inappropriate conduct and incompetence within the VA that led to well-documented deaths and delays. The report also exposes the inept congressional and agency oversight that allowed rampant misconduct to grow unchecked.

“This report shows the problems at the VA are worse than anyone imagined. The scope of the VA’s incompetence – and Congress’ indifferent oversight – is breathtaking and disturbing. This investigation found the problems at the VA are far deeper than just scheduling. Over the past decade, more than 1,000 veterans may have died as a result of the VA’s misconduct and the VA has paid out nearly $1 billion to veterans and their families for its medical malpractice. As is typical with any bureaucracy, the excuse for not being able to meet goals is a lack of resources. But this is not the case at the VA where spending has increased rapidly in recent years,” Dr. Coburn said.

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