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. I’m glad to be back.
Fred Baker
Well, as always, we’re happy that you’re here so we can discuss some of our oversight work and the lessons that can be learned from it.
We’re here today to talk about Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico.
So, as we typically do, go ahead and please provide some context on the size and the capabilities of the facility.
Trina Rollins
Sure. So, VA New Mexico Health Care System is part of VISN 22, as was explained in the title. It includes the facility and 13 community-based outpatient clinics. The facility is classified as a level 1B, which is a high complexity facility, and it has 167 hospital beds, 36 community living center beds, and 70 domiciliary beds.
Fred Baker
So, thanks, Trina. Give us a little background on how we received this allegation and then tell us what’s involved in reprocessing of reusable medical devices. What does that even mean?
Trina Rollins
Sure. So, in April of 2023, we actually received a complaint alleging that the chief of the sterile processing service failed to ensure instrument reprocessing, failed to maintain disinfection records, and failed to perform quality assurance activities for the reusable medical devices, as required. For background purposes, reprocessing is a term used to describe the steps involved in making the contaminated reusable medical device ready for reuse. So that means cleaning it, disinfecting it, and sterilizing it. And there are very specific manufacturers’ directions on how to do that depending on what the device is.
Fred Baker
So, what types of medical devices are reusable?
Trina Rollins
Mostly endoscopes. So, you can have a scope going down your throat into your stomach. The scope usually has a little camera on the end of it so the provider can look around. For instance, if they’re going down your throat, they may be looking for ulcers or bleeding.
The opposite of that, you’ve heard of colonoscopies where they use the scope to go up into the colon and look for cancers and masses. And again, same thing is, it’s got a camera on the end, and that equipment is inserted into the rectum and up into the colon and allows the provider to look around.
But that equipment is very, very expensive. So, you want to be able to reuse it, clean it appropriately to prevent any transfer of infection or body fluids to the next person.
And that’s what we’re talking about here, is that reprocessing of the equipment. Other things that can be reprocessed are surgical instruments. So not usually a scalpel—that’s a disposable—but things like forceps and pickups, those instruments that are used in multiple types of surgeries.
Fred Baker
And you mentioned different devices have different procedures. I’m assuming they’re cleaned different ways, different chemicals.
Trina Rollins
Correct.
Fred Baker
And who is typically doing this cleaning?
Trina Rollins
They’re specialist in sterile processing.
Fred Baker
So, they’re specialists who do this day in, day out?
Trina Rollins
Correct. They have to be trained appropriately and understand the chemicals that are used. Understand where to find the manufacturer’s instructions. And then, of course, the disinfecting solutions as well as the machines. They have to understand the use of those as well.
Fred Baker
So, because of the nature of what these devices are used for, they can create some pretty serious risks for patients if this reprocessing isn’t done correctly.
Trina Rollins
Correct. The biggest risk is infection. And, you know, depending on the patient, if, say, it’s a cancer patient and you use an instrument that wasn’t disinfected properly, you could introduce an infection that could be lethal for that patient. In other patients that are a bit more healthy, you could have a serious infection related to that.
So, yes, we want to prevent any type of infectious disease from occurring because of not disinfecting this equipment appropriately.
Fred Baker
So go back again real quick and tell me what the specific allegations were.
Trina Rollins
The specific allegations were that the chief of the service failed to ensure instrument reprocessing, didn’t maintain disinfection records, and didn’t perform the quality assurance activities needed to monitor the processes within Sterile Processing Service.
Fred Baker
So, in the report we talk about lacking documentation. What does that mean? How important is this documentation and could these instruments have been reprocessed correctly and just not have the paperwork completed properly? Basically, was this a disinfection problem or a paperwork problem?
Trina Rollins
Well, the short answer is because we don’t know whether or not —because we don’t have the paperwork, we don’t know whether or not the equipment was disinfected properly. So, I mean, I think you’ve heard the old adage, “If it’s not documented, it’s not done.” In this case, that’s truly what we have to go by because of the severity of the consequences.
If it’s not documented properly and it’s not documented in the system so that we can track the cleaning, the disinfecting, the sterilization, then we don’t know if it’s processed appropriately. And we don’t know, we can’t say for sure that it would prevent or not contribute to some type of infection in the patient it’s used in.
Fred Baker
So, what were our findings in this?
Trina Rollins
We did substantiate that documentation verifying the completion of the disinfection process was missing.
We actually looked at joint patient safety reports, which is a way a staff member can report any type of concern or issue. And it can be this type of issue, it could be, you know, a patient fall, a medication error. But that’s the way VA uses to help report those issues, and then they turn around and do a review to try and figure out, is this a systemic problem or is this a one off and try and get to the bottom of how and why that occurred.
So, we looked at the JPSRs to try and find instances of inaccurate documentation in the sterilization process. So, then we would look at those patients and determine whether or not there was any harm, because again, we can’t say for sure 100 percent that the disinfection process was completed accurately. So, when we found those, what we did was look at the JPSRs, looked in the medical records for any type of follow-up infection that occurred after a procedure that used these scopes that we couldn’t determine whether or not they had been reprocessed, appropriately.
The good news is we didn’t find any. We did our review. The gastrointestinal service at the facility did a review. They didn’t find any harm either. And so, I think we’re pretty confident that the equipment that was used that we can’t track the documentation on didn’t cause any type of harm to the patient.
Can we infer that in that instance it was reprocessed appropriately? Maybe. But again, without the documentation, we can’t say 100 percent that it was processed appropriately.
Fred Baker
So, did we find out or hear from them about why there was no documentation?
Trina Rollins
So yeah, there was—the SPS staff has a specific procedure they need to follow when reprocessing this equipment and in some of the instances they omitted the receipt. So, as you disinfect a piece of equipment, the machine that you use is actually giving you a receipt of that. It’s telling you when it was reprocessed, it gives you a date and time stamp and then that is attached, or they actually use a scanning method because each piece of equipment has its own barcode. And that way you can connect that receipt to that piece of equipment and know for sure it was disinfected on whatever day, at this specific time. So, some of those receipts weren’t being scanned with the equipment.
Part of the issue had been previously that the receipts were illegible. The print was too faint, and so you couldn’t read what it said. So again, if you can’t read the receipt, how do we know it’s the appropriate receipt for that piece of equipment?
Other times, the SPS staff were entering information manually. And I think we all can agree when you enter information manually there’s always room for an error to occur.
Also, at times the staff were cleaning multiple loads at one time. So, using multiple disinfecting machines at one time. And, you know, when you have that kind of volume going at the same time, again there’s room for error.
Fred Baker
Sure. I would like to bring up one very interesting allegation in this report, and that was the allegation they were being discouraged about reporting this to the OIG. Was there any truth behind that?
Trina Rollins
Again, if people that are listening to the podcasts aren’t aware, if you want to report something to the OIG, you can actually do it anonymously. So, there is no record of your name or you filing a report. You don’t have to leave your name. You don’t have to leave a contact number.
So, we didn’t find any evidence that someone was actually discouraging people from reporting issues. What we actually found was that, through the records that we reviewed, people were reporting issues. They were continuing to report issues.
Fred Baker
So that’s a good thing.
Trina Rollins
It’s a good thing. Yeah. So, in the overall aspect of trying to be a high reliability organization, which VHA has pledged to do, we want staff to report issues because then those issues can be reviewed. And if there is a systemic problem involved, that’s one way of addressing it. And again, it’s addressing it on a higher level and hopefully preventing further incidents from occurring down the road.
Fred Baker
Sure. And just to be clear, a supervisor cannot tell an employee to not report to the OIG, regardless of whether they do it anonymously or not.
Trina Rollins
Correct. Correct.
Fred Baker
Great. So, what were our recommendations?
Trina Rollins
We made three recommendations to the VISN because we were concerned with some timely communication of previous audit reports that the VISN did. So, the VISN had done an audit that showed some deficiencies but didn’t provide those results in writing to the facility for several months, which then delayed the ability of the facility to put into action ways to address those issues.
So again, we’re making recommendations to the VISN to ensure that they timely communicate those audit results because in the long run that’s going to help the facility address those issues.
We made four recommendations to the facility director related to completion and oversight of daily quality assurance activities. So again, it’s looking at those receipts, making sure that they’re attached to the right piece of equipment, that they’re legible, and that all the pieces are there. Also identifying and resolving any documentation errors that were present as they occur. So, you know, if they’re doing audits every day, which they should be doing, you know, those daily checks, if they find something, then they can address it that day before the equipment actually leaves the Sterile Processing Department and goes to the OR or the procedure room where it will be used on a patient.
We recommended that the Sterile Processing Service leaders communicate to staff regarding their specific roles and responsibilities. In the report, you’ll see some information about a quality review nurse. And again, that’s an additional staff person that is there to help review all of these aspects and ensure that the quality of the disinfecting processing is occurring, the documentation is correct and, again, helps to assure that those processes are taking place.
Fred Baker
And what was the facility’s response?
Trina Rollins
The response? The VISN and the facility directors both concurred with the OIG’s recommendations and, as always, we’ll continue to follow any actions that they enact and look for sustainability of those actions before we close any of those recommendations.
Fred Baker
Well, thank you, Trina. I think this was very good report, some solid lessons learned for those in these facilities. Do you have anything to add?
Trina Rollins
I don’t. Thanks, having me again, Fred.
Fred Baker
As always, a pleasure. And we’ll get together again soon for another podcast. 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 Veterans Crisis Line. Dial 988 and then press 1. Now let’s go to Lauren for the highlights of our oversight work for this past month.
[Music]
Lauren O’Connor
Thanks, Fred.
Steve Bracci, director of the Compensation Programs Division in the OIG’s Office of Audits and Evaluations, testified on July 23 before the House Veterans’ Affairs Committee’s Subcommittee on Disability Assistance and Memorial Affairs. He highlighted findings and recommendations from seven OIG reports on disability compensation claims processing by VBA staff. He also discussed the challenges VBA faces in meeting the objectives of its quality assurance and training programs. In response to questions, he highlighted the steps the Department must take to effectively implement OIG recommendations.
Steve Bracci
I appreciate the opportunity to discuss the OIG’s oversight of VBA’s quality assurance and training programs related to disability claims. While VBA has made enhancements to its quality assurance program, there is still work to be done. That program is intended to help ensure timely, accurate, and consistent claims decisions, and VBA’s training program must prepare new and current employees to follow complex and frequently changing guidance. Given that millions of veterans and family members will receive over 150 billion dollars in disability benefits this fiscal year, the OIG is committed to continuing its independent oversight to provide VBA with meaningful recommendations for improvement. As detailed in my statement, we have persistently identified challenges to both programs. Four OIG reports from the last few years address such critical areas as: one, processing errors made on veteran's individual unemployability claims; two, inconsistencies implementing changes to the disability rating schedule; three, issues with claims automation; and four, unwarranted medical reexaminations of veterans.
Lauren O’Connor
You can find Mr. Bracci’s full written statement, as well as a video of his testimony, in the congressional relations section of the VA OIG website.
Meanwhile, thirteen OIG investigations had significant developments in July.
According to a multiagency investigation, numerous individuals allegedly engaged in a scheme to solicit and receive kickbacks from multiple North Texas compounding pharmacies in return for directing prescriptions for patients in federal programs to those pharmacies. The total loss to the government is more than $6 million. Of this amount, the loss to VA is over $848,000. Two owners of a health services company pleaded guilty to conspiracy to solicit and receive kickbacks. They were sentenced in the Northern District of Texas to 14 months and 15 months in prison, respectively, and they each received one year of supervised release. Each owner was also ordered to pay over $4.4 million in restitution.
Three other investigative highlights concern veterans making threats towards VA facilities in several states. In one of these cases, a veteran threatened to blow up the VA medical centers in Buffalo, New York, and Washington, DC, via several telephone calls and text messages to the Veterans Crisis Line. The veteran was sentenced in the Western District of New York to time served—101 days—and one year of supervised release after pleading guilty to assault and intimidation of federal employees.
Read more about the latest OIG investigative updates in the July monthly highlights, which can be found under the reports tab on our website.
Now turning to reports, the Office of Audits and Evaluations issued two management advisory memoranda in July. You may remember that the OIG issues management advisory memoranda when exigent circumstances or areas of concern are identified by hotline allegations or during our oversight work, particularly when immediate action by VA can help reduce further risk of harm to veterans or significant financial losses.
The first memorandum is about the VHA’s Program Integrity Tool.
The VHA uses data from the Program Integrity Tool to determine if healthcare claims from community providers should be billed to veterans or private insurance companies for treatment of conditions not related to military service. The tool is also used to detect waste or fraud, such as duplicate claims payments.
In February 2023, VHA paused the tool’s operations after becoming aware of issues with its database code logic and that stored data had been compromised. While the tool is offline, community care claims continue to be received and paid through the claims processing payment systems. However, VHA cannot bill veterans or private insurance companies for community care claims dated after the pause. As a result, there will be a backlog of about 40 million paid community care claims that must be processed when the tool is reactivated. The OIG estimates that the pause has resulted in about $665.5 million in collections that had not been recovered as of February 2024.
According to the second management advisory memorandum, VBA did not always properly implement compensation cost-of-living adjustments, also known as COLA,.VA provides tax-free monthly compensation to veterans for service-connected disabilities, including special monthly compensation for certain serious disabilities or combinations of disabilities. The OIG identified instances in which VBA did not properly implement each annual COLA for disability compensation.
The team found that certain special monthly compensation amounts had been calculated incorrectly for each annual COLA since December 1, 2016, resulting in some monthly payments being slightly higher or lower than they should have been. The team also found that the increased amounts for disability compensation, additional compensation for dependents, and clothing allowance for the COLA effective December 1, 2022, were not published in the Federal Register, as required.
In addition to these memoranda, the OIG issued nine other reports in July. Three of the reports addressed concerns about suicide prevention. I’ll highlight just one of these reports.
The OIG substantiated allegations that staff at the VA medical center in Shreveport, Louisiana, failed to meet multiple VHA Suicide Prevention Program policy requirements in the care of two patients, one of whom died by suicide. In addition to mismanaging flags indicating a high risk for suicide in patient records, staff failed to complete suicide-risk screening and assessments, document Veterans Crisis Line request responses, and take proper actions following a suicide. The team also identified concerns related to one-to-one patient observation staffing as well as posting and recruiting for suicide prevention program vacancies. The OIG made one recommendation to the VISN director related to suicide prevention staffing and seven recommendations to the facility director regarding compliance with suicide prevention policy and one-to-one observation staff assignments.
Thank you for listening to this summary of the OIG’s recent work. You can read the full July monthly highlights on our website at www.vaoig.gov.
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 veteran’s crisis line at 1-800-273-8255, press 1 and speak with a qualified responder now.