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Veteran Oversight Now is an official podcast of the Department of Veteran Affairs, Office of Inspector General. Each episode features interviews with key stakeholders, discussions on high-impact reports, and highlights of recent oversight work. Listen regularly for the inside story on how the VA OIG investigates crimes and wrongdoings, audits programs that provide benefits and services to veterans, and inspects medical facilities to ensure our nation’s veterans receive safe and timely health care.
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. Welcome, Trina.
Trina Rollins
Thanks, Fred. Glad to be here.
Fred Baker
We're here today, unfortunately, to talk about one of our more tragic reports, one of our reports that focuses on some of the more tragic events that we have to discuss for the lessons that we can learn from them. The report is Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas. Before we begin, as we typically do, if you can give me some context on the size and the capabilities of the facility.
Trina Rollins
I sure can. VA Southern Nevada Healthcare System is in Las Vegas, Nevada. It's part of VISN 21 and is designated a level 1b, high complexity facility. The facility has 140 operating beds and provides medical, surgical, and mental health services and supports seven outpatient clinics in Nevada, including the Laughlin Clinic, where the veteran that is the subject of this report received care. Just so our listeners understand, the Laughlin Clinic is located about 111 miles away from the main facility where the outpatient pharmacy is located.
Fred Baker
And the facility at which he received care, they were capable of providing services for this event. Correct?
Trina Rollins
Correct. They understood what needed to be done.
Fred Baker
Right.
Trina Rollins
This is not an unusual process, put it that way.
Fred Baker
So how did this hotline come to us?
Trina Rollins
So, the complaint was actually submitted by a family member and alleged that facility staff delayed approval of a prescription medication following the patient's discharge from a community hospital. The family member reported the patient was concerned about the high out-of-pocket costs for the new medication and completed suicide while awaiting the medication delivery from VA.
Fred Baker
Wow. Give us a little background on the patient. It sounds like there were several health issues and they were in their eighties.
Trina Rollins
Yes, the patient was in their eighties and had a medical history that included diabetes, high blood pressure, high cholesterol, and chronic kidney disease. The patient actually presented to a community hospital emergency room with shortness of breath and an abnormal EKG, meaning—which could indicate that the patient was having a problem with their heart.
Fred Baker
So, let's talk about the demographics of this patient. Is this demographic typical of those who seek care at VA medical facilities?
Trina Rollins
Currently, yes. You know, the patient was in their eighties and had multiple medical problems. That is very representative of our Vietnam veteran population. Our OEF/OIF/OND veteran population are getting older, and many of us as we age will develop other disease processes. So again, that's not unusual. And, you know, with the elderly population, it's not unusual for them to have limited income or be on a fixed income.
Fred Baker
So, with respect to this event, you mentioned that they presented at emergency care. Can you kind of walk us briefly through the timeline and we'll talk a little bit more about the details at some of the critical points?
Trina Rollins
Sure, I can do that. The patient went to an outside facility, a community facility emergency department, because they were short of breath. That facility admitted them to the hospital and that patient was admitted for about a week before the community hospital made any contact with VA. And just so you know, that type of communication should be done the same day or within 72 hours of a veteran presenting to an emergency department that's not VA associated. So, you know, that's important in helping to get the care coordination started. Around day nine of the admission, the patient, you know, had been there nine days. The patient actually made a call to the primary care nurse at the VA asking for help in coordinating discharge from the community facility. But it was two days later before the nurse called the patient back. Well, come to find out, the patient had already been discharged. And so, the nurse instructed the patient to come to the clinic, bring discharge paperwork, and so that they could get the discharge medications ordered. Well, unfortunately, that didn't happen.
Fred Baker
Let's pause just there real quick.
Trina Rollins
Okay.
Fred Baker
So the community care hospital discharged them and said, “Here's your paperwork. Here are the meds you need.” That patient then called VA looking for assistance.
Trina Rollins
Actually, they called before.
Fred Baker
Looking for assistance, get discharged.
Trina Rollins
Yeah.
Fred Baker
Right. So in between that, they were discharged.
Trina Rollins
They were discharged.
Fred Baker
And why did it take two days for them to call the patient back?
Trina Rollins
That was a breakdown in process. Yeah. The expectation is a same day call, or at least the next day.
Fred Baker
Okay. So go ahead and continue then.
Trina Rollins
Okay. So, the patient and a family member came to the clinic and presented the discharge paperwork that was given at discharge. The primary care nurse documented in the medical record that the patient had congestive heart failure and was prescribed an external defibrillator vest and needed a VISN Clinical Resource Hub appointment because the patient's provider was not available that day. This was a new diagnosis for the patient. The patient was prescribed new medication that they had never taken before. They were prescribed an external defibrillator vest, which, if you don't know what that is, if your heart were to stop suddenly that vest being worn would give the patient a shock to you try and restart the heart. So, you know, that tells the reader or the listener that he was having some—that tells the reader or the listener that the patient was having some significant heart problems. The Clinical Resource Hub, that's another resource that’s available within VA. It's usually a telehealth or the VVC, Video Connect type appointment, and its coverage when a primary care provider may be out of the office or unavailable. It's another resource that VA staff can use to get appointments for patients.
Fred Baker
Sure.
Trina Rollins
So, the patient actually—this happened on a Friday and the following Monday, the patient had the appointment, a telephone appointment with the VISN clinical resource provider. Unfortunately, the provider was having technical issues and couldn't access the patient's medical records and so couldn't see any of the documentation that had already been inputted about the patient's discharge and the discharge diagnoses. The provider did understand that the patient was on a new medication to prevent blood clots called apixaban. And that's a medication that requires special authorization within VA. Instead of placing the special authorization consult, the VISN provider placed a consult to the anticoagulation clinic, which, again, was not the correct process to take. The VISN provider also recommended a consult to cardiology because of all the cardiac or heart-related issues that the patient was having, but unfortunately didn't place the consult. So, it was later that the patient's primary care provider took a look at the chart and the notes and actually placed that consult to cardiology. Once the primary care provider looked at the records, that's when it was noted that the specific authorization for the medication apixaban had not been placed. So, the primary care provider is actually the one that placed that prior—it's called a prior authorization drug request to get the medication for the patient.
Fred Baker
Right.
Trina Rollins
But unfortunately, it was two days later before it was approved. So, if you go by the timeline, this is 17 days after the patient first visit the emergency room with the shortness of breath problems. The pharmacy did process and approve the prior authorization request for apixaban, but then mailed it to the veteran by standard mail. And I think all of us understand standard mail, depending on where you are in the country, could be two days. It could be two weeks. We have no control over when we can receive, when we receive the mail. Unfortunately, the patient completed suicide that same day without receiving the medication.
Fred Baker
So, was that standard, to mail it by standard mail?
Trina Rollins
I would say yes and no. You know, in this situation, no. I think it should have been expedited because, again, if you look at the timeline, you will see there have been already several delays in this patient's care. If it had been, you know, the day of discharge or the day after discharge sent by standard mail, again, it's a possibility that the patient—it would have been fine to send it by standard mail. But I would also argue that this is a medication that prevents blood clots. So, you're trying to prevent a stroke or heart attack or some other catastrophic event in this veteran. So, just because of the type of medication, I would argue that it should have been mailed expedited, no matter what.
Fred Baker
And I kind of feel like that's what kind of along this process is kind of difficult to understand. You have a patient in their eighties with obviously very serious heart issues. Quite frankly, time is of the essence on appointments and consults and medicines. I would think so.
Trina Rollins
I agree. And that's why the care coordination is so important in these patients.
Fred Baker
And it was at various steps in that care coordination that things were dropped. Correct?
Trina Rollins
Correct. Yes.
Fred Baker
I do want to clarify the care providers in this report because it can get a little confusing. There was a community care nurse, a primary care staff, primary care provider and a VISN physician. Of those, who are VA employees?
Trina Rollins
Actually, all of them are VA employees. So, the community care nurse works in the Community Care Department, and their responsibility is to coordinate any care that a veteran receives outside of VA. So again, that's the person that should have been in contact initially with the community provider, the community hospital, and should have been working to coordinate the discharge and bringing them back into VA. The primary care staff and the primary care provider work in the primary care clinic at the VA and manage the overall care of a patient. They can make needed referrals for specialty care or specialty medications. The VISN Clinical Resource Hub physician works for the VISN. It's a program that's supported by the VISN and helps to increase access to care. So again, this is a way to connect when a primary care provider may not be available immediately. So again, they're all VA employees, so they all should have an understanding of the way the process works.
Fred Baker
And should have all been connected into this continuity of care.
Trina Rollins
Correct.
Fred Baker
Trina, let's walk through the findings. There were a few. The first is that the community care nurse provided inadequate care coordination.
Trina Rollins
Yeah. So, I've already alluded to this a little bit. The community care nurse was notified seven days after the patient was admitted. So, again, I don't know that the community care nurse was at fault. But again, when the notification was made, the documentation that was placed into the medical record was delayed. The information that was needed to assist the patient with coordinating discharge, the discharge arrangements was delayed. And I mean, and as we see if you read through the report, the accurate documentation of the patient's admission status and the admission diagnoses—they were both needed to get the care that the patient needed. This patient was also on oxygen. So, again, it takes more than just calling up an oxygen company to get oxygen delivered to, you know, a new patient needing oxygen. That needs more than a day's worth of coordination. So, again, the community care nurse failed to provide this proactive clinical care coordination to prepare the patient for discharge.
Fred Baker
And then we found that primary care staff failed to provide health education and same day access?
Trina Rollins
Correct. When the patient came to the clinic with the discharge summary, the staff in the clinic would have been expected to provide patient-centered care, meaning they would have been responsible for assisting or coordinating that care that was provided in the community and transitioning the patient back to the VA. They're expected to respond to a patient's contact within one business day or preferably sooner. You know, again, this patient made contact with the VA the day before discharge and didn't get the call back for two days. But again, the expectation is same day or at least the next business day. The primary care nurse also failed to instruct the patient and the family on how to obtain the community hospital prescribed medications from the VA. You know, didn't go through that process. So, there was questions all around and misinformation all around about how to fill those prescriptions.
Fred Baker
And the primary care provider failed to order the discharge medications.
Trina Rollins
Yeah. So, you know, this patient ended up having seven brand new medications started at the community hospital. Some of those could have been ordered very quickly. Others required this prior authorization. The patient and the family brought an 18-page discharge summary to the clinic, but the PCP or the primary care provider said they couldn't order the medications because the discharge diagnosis was missing from the discharge paperwork. But that information was already in the patient's medical record. The community care nurse had documented what the diagnoses were when that documentation had occurred initially. So again, this was just further delaying the patient receiving the needed medication.
Fred Baker
Yeah. And so finally, the VISN physician lacked the clinical information needed to conduct the post-discharge care and then also did not order the anticoagulant medicine or medication.
Trina Rollins
Yeah. So, this, you know, this Clinical Resource Hub physician, the whole program is used to, as a stopgap when a primary care provider may not be available. But, you know, this physician didn't conduct a complete medication reconciliation, which is really important when you're looking at discharge medications. What that entails is looking at the medications that the VA prescribes to the veteran and comparing it to what the community provider was prescribing, noting the changes, because in this case, some of the medications that the veteran had been taking was stopped and new medications were started. So again, explaining all of that to the veteran and then making sure that those orders are placed properly. Also, the VISN physician didn't enter a return to clinic order, so the patient didn't have a follow-up appointment with their primary care provider. The VISN provider placed an anticoagulation clinic consult instead of the prior authorization drug request for the apixaban, the specialized medication. So again, they didn't understand or didn't know the process. And so, this caused further delays in the patient getting the medication.
Fred Baker
So, Trina, this was definitely a tragic event and there were missteps along the way at various levels. What were our recommendations?
Trina Rollins
So, we made one recommendation to the VISN that the network director review the patient's course of care and determine if any further actions are warranted. We made four recommendations to the facility director related to community care coordination, primary care processes and actions requiring, required following a patient's death by suicide. And we didn't cover that in the podcast today, but there are issues with how the facility responded once they found out the patient had died by suicide. And so, if you're interested in that, please read the report.
Fred Baker
So, what was the facility's response?
Trina Rollins
So, both the VISN network director and the facility medical director concurred with our recommendations and stated that they're committed to providing processes—to improving processes—to ensure high quality health care for veterans.
Fred Baker
And we're satisfied with that response.
Trina Rollins
So again, we will continue to follow the recommendations and review any evidence that the VISN or the medical center provides us to make a determination on whether or not we closed those recommendations.
Fred Baker
Well, Trina, thank you very much. As always, we appreciate you walking us through these reports and helping us pull out the lessons learned. Anything else you'd like to add?
Trina Rollins
No, I don't have anything to add. I just, I appreciate the time, and I hope it's beneficial for those listening.
Fred Baker
Well, thank you, Trina.
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.vaoig.gov/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 one. Now, let’s to Lauren for the highlights of our oversight work from this past month.
Lauren O’Connor
Thanks, Fred.
The VA OIG went to Capitol Hill three times in June to testify before congress. Inspector General Michael Missal testified before the House Veterans’ Affairs Committee on June 4th. His testimony focused on an OIG oversight report published in May that found the VA improperly awarded $10.8 million in critical skills incentives to executives in the VA central office in 2023—you may remember that we talked about this report in our last VON podcast. Mr. Missal stated that VA’s actions to make a blanket award of these incentives to 182 VA central office senior executives was inconsistent with law and policy. Here’s an excerpt from his testimony.
Mike Missal
Our work found lapses and governance, judgment, due diligence, communications, and accountability at multiple levels of VA. We made two findings. First, that the award of CSIs to nearly all VACO senior executives in VHA and VBA was inconsistent with the PACT Act and VA policy based on the following: VHA and VA improperly grouped all VACO senior executives together, contrary to VA’s own policy to narrowly define a group for incentive pay. Next, the amounts awarded were determined without considering what was needed for retention, and further, VHA provided no market factors in support of its CSIs. VBA’s justification was based on flawed assumptions without analysis.
Lauren O’Connor
On June 13th, Stephen Bracci, director of the Compensation Programs Division in the OIG’s Office of Audits and Evaluations, testified before the same committee about VA’s oversight of the contracts for medical disability exams used when deciding veterans’ compensation and pension claims. Listen to this clip from his testimony.
Stephen Bracci
While we are not ADA or OSHA compliance officials able to cite specific violations, we did identify deficiencies at 113 of the 135 facilities we visited. These deficiencies created needless burdens and safety concerns for veterans with mobility issues and those with spinal cord injuries and disorders. We found that the deficiencies went largely undetected by MDEO because that office did not provide sufficient oversight of the vendors’ self-certification of ADA and OSHA compliance.
Lauren O’Connor
Finally, Dr. Julie Kroviak, Principal Deputy Assistant Inspector General for Healthcare Inspections, was a witness before the House Veterans’ Affairs Committee’s Subcommittee on Health. She discussed OIG work that repeatedly found inadequate oversight by the leadership of VA’s Veterans Integrated Service Networks. Here, she talks about issues that highlight an ineffective VISN structure.
Dr. Julie Kroviak
Unclear reporting lines, optional participation of facility leads in sharing critical metrics with VISN leaders, and general confusion over VISN authority undermine the essential functions of medical facilities and further highlight a VISN structure that is ineffective in ensuring consistent delivery of safe care to patients. Ultimately, in a healthcare system as large as VHA, lack of a standardized leadership structure hinders progress and increases risks.
Lauren O’Connor
You can find the written statements for all of these hearings—as well as a video of each person’s testimony—in the congressional relations section of the VA OIG website. Now let’s turn to the work of our Office of Investigations. A VA OIG investigation revealed that a former registered nurse at the West Haven VA Medical Center in Connecticut diverted controlled substances intended for the facility’s intensive care unit patients approximately three times a week over six months. To cover up her crimes, the defendant misrepresented in VA medical records and tracking systems that she administered the narcotics to the patient or properly disposed of the remaining unused portion. The defendant pleaded guilty in the District of Connecticut to obtaining a controlled substance by fraud, deception, or subterfuge.
Another investigation revealed that the owner and the certifying official for a non-college-degree school conspired to submit fraudulent information to conceal the entity’s noncompliance with the rules and regulations of the Post-9/11 GI Bill program. In response to an inspector general subpoena, the owner and certifying official provided fraudulent information, including falsified contracts and rosters. Between September 2012 and August 2018, VA paid over $17.8 million to the school, which subsequently withdrew from the Post-9/11 GI Bill program. The defendants pleaded guilty in the District of New Hampshire to conspiracy to commit a false statement.
The last case I want to talk about concerns a VA fiduciary. A VA OIG and Social Security Administration OIG investigation revealed that a former VA-appointed fiduciary made large monthly cash withdrawals of VA funds intended for a veteran and used the funds for her own personal expenses. The former fiduciary was sentenced in the Middle District of Florida to six months of home confinement, 36 months of supervised release, and restitution of over $103,000 after pleading guilty to theft of government funds.
Now to reports. The VA OIG published nine reports in June.
The VA OIG conducted an audit to assess how much VHA medical facilities use the Medical/Surgical Prime Vendor program for cost-effective ordering and distribution of healthcare supplies. The OIG found that medical facilities did not always purchase through the program. Items were often unavailable on the Medical/Surgical Prime Vendor product list, or staff did not check the list before ordering from the open market. Issues with availability often go unreported due to challenges with the reporting tool and quicker results through local workarounds. The audit team found that the program office and medical center leaders have not provided effective oversight. In 2022, VHA could have saved approximately $35.5 million if facilities had ordered items eligible through this program instead of the open market. The team also determined that medical facilities spent about $1.5 billion on items not available through the program at all. The OIG made nine recommendations to the under secretary for health, including identifying a VA-owned system where staff can check product availability and price, reviewing open market purchases, improving training on Medical/Surgical Prime Vendor usage and tools, and ensuring staff report unavailable items.
The OIG also issued a management advisory memorandum in June that identified potential weaknesses in the VISN 20 Personnel Suitability Program. A whistleblower alleged that untrained human resources officials from VISN 20 were overturning prescreening determinations for potential employees. The complainant’s documentation identified five candidates initially found unsuitable for employment due to potentially disqualifying conduct, such as domestic violence and driving under the influence. The team determined that human resources officials in VISN-20 reversed an adjudicator’s unfavorable determination in two of the five instances but did not violate VA policy. However, these officials did not complete required adjudicator training for staff reviewing suitability determinations. The team also identified inconsistencies in the management and monitoring of the prescreening process. In its comments to the memorandum, VHA reported taking action to establish decision-making roles and improve the review process for suitability coordinators.
The last report I want to mention is titled Leaders at the VA Eastern Colorado Health Care System in Aurora Created an Environment That Undermined the Culture of Safety. The OIG substantiated allegations that senior leaders did not employ high reliability organization principles and created an environment in which many clinical and administrative leaders and frontline staff felt psychologically unsafe, deeply disrespected, and dismissed, and they feared that speaking up or offering a different opinion would result in reprisal. The inspection found instability in leadership, with many clinical service and section-level resignations and vacancies. The OIG made two recommendations to the under secretary for health, four recommendations to the VISN director, and one recommendation to the facility director.
Finally, the June monthly highlights features a hotline case about a beneficiary who was fraudulently in receipt of Dependency and Indemnity Compensation due to their divorce and subsequent remarriage before the veteran died. The matter was referred to the VA regional office in Saint Paul, Minnesota, who sent the beneficiary a due process notice that termination of benefits was being proposed. In response, the beneficiary submitted documents that purported she was married to the veteran at the time of his death. The regional office’s research found a marriage certificate for the beneficiary and another party before the veteran’s death as well as evidence that the veteran self-reported his divorce from the beneficiary. The regional office terminated the benefits and established a debt for the fraudulent payments.
To learn more about this or other OIG work in June 2024, read the monthly highlights under the reports tab on our website at www.vaoig.gov.
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. 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.