By Walter F. Roche Jr.
A multimillion dollar U.S. Veterans Affairs rebranding effort included improperly awarded contracts and failure to produce any evidence of its effectiveness in increasing the use of services by veterans, an audit report has concluded.
The report issued Thursday by the VA's Inspector General concludes that anonymous allegations of mismanagement were "substantiated" along with charges that the contract was doubled without soliciting new bids.
Overall, according to the audit, the VA paid $10.2 million to a Vienna, Va. firm, Woodbridge Studios, without any evidence that the six market advertising campaign brought in any more veterans, the ostensible goal.
The value of the contract jumped from $5.2 million to $10.2 million through a contract modification that the report called "questionable."
The television ad campaign in late 2010 and early 2013 included spots on the Super Bowl and the Country Music Awards.
"In general we found the Woodbridge time and materials contract to be open-ended with no direct link between resource input and tangible program outcomes," the audit concludes.
The report criticizes the original Woodbridge contract for "the lack of specific deliverables" and for the questionable use of a payment system based on the hours worked.
The VA "also lacked performance metrics to fully assess and monitor outreach campaigns to ensure increases in access."
The report also criticizes the VA for awarding a second $4 million
contract to the Ad Council. A Woodbridge executive was involved in
overseeing that contract. The report states that the second contract was
awarded without evaluating the effectiveness of the first.
In response to the audit, VA officials blamed significant employee turnover and two key unfilled positions for the lack of oversight of the rebranding efforts. They agreed to a series of steps to avoid a recurrence.
Woodbridge officials did not respond to a request for comment.
wfrochejr999@gmail.com
Thursday, November 20, 2014
Monday, November 17, 2014
Indiana Vet's Suicide Followed Multiple Care Lapses - OIG Report
By Walter F. Roche Jr.
A critical report on the 2013 suicide of an Indiana veteran concludes that Veterans Affairs health care providers missed multiple opportunities to provide needed care and even failed to read his entire electronic medical record, which contained multiple indications he was a suicide risk.
The 33-page report issued Monday concludes that while the final outcome might not have changed actions and in-actions by VA staffers "compromised the patient's mental health."
The review, which was requested by U.S. Rep. Jackie Walorski, notes that physicians continued the unnamed veteran on a high dose regimen of a steroid, prednisone, despite warnings that there was evidence that it was causing severe mood swings.
Side effects of that drug with prolonged use range from mild depression to mania and delirium, the report states.
The veteran, who lived in Marion, had multiple diagnoses indicating he was a suicide risk including bipolar disorder and post traumatic stress syndrome. He died of a self inflicted gunshot wound.
In addition both the patient and his wife had stated verbally that he was contemplating suicide due to excessive pain.
Shortly before his death, the wife of the veteran, told his health care providers that her husband was in so much pain he was "ready to blow his brains out."
In addition a rheumatologist who treated the patient had noted in the VA record that the patient "did not require steroid therapy."
"Although the outcome may have been the same for this patient, there were several missed opportunities where the patient's care and effectiveness could have been improved," the IG's report states.
Citing communications breakdowns and "failure to review information available in the patient's electronic health record," the report concludes that the patient's mental health was compromised."
The VA, in response to the report, agreed to more than a dozen recommendations aimed at avoiding a recurrence.
According to the report the veteran committed suicide in December of 2013 after he had sought care at at least three VA facilities and an unnamed private health care agency.
A critical report on the 2013 suicide of an Indiana veteran concludes that Veterans Affairs health care providers missed multiple opportunities to provide needed care and even failed to read his entire electronic medical record, which contained multiple indications he was a suicide risk.
The 33-page report issued Monday concludes that while the final outcome might not have changed actions and in-actions by VA staffers "compromised the patient's mental health."
The review, which was requested by U.S. Rep. Jackie Walorski, notes that physicians continued the unnamed veteran on a high dose regimen of a steroid, prednisone, despite warnings that there was evidence that it was causing severe mood swings.
Side effects of that drug with prolonged use range from mild depression to mania and delirium, the report states.
The veteran, who lived in Marion, had multiple diagnoses indicating he was a suicide risk including bipolar disorder and post traumatic stress syndrome. He died of a self inflicted gunshot wound.
In addition both the patient and his wife had stated verbally that he was contemplating suicide due to excessive pain.
Shortly before his death, the wife of the veteran, told his health care providers that her husband was in so much pain he was "ready to blow his brains out."
In addition a rheumatologist who treated the patient had noted in the VA record that the patient "did not require steroid therapy."
"Although the outcome may have been the same for this patient, there were several missed opportunities where the patient's care and effectiveness could have been improved," the IG's report states.
Citing communications breakdowns and "failure to review information available in the patient's electronic health record," the report concludes that the patient's mental health was compromised."
The VA, in response to the report, agreed to more than a dozen recommendations aimed at avoiding a recurrence.
According to the report the veteran committed suicide in December of 2013 after he had sought care at at least three VA facilities and an unnamed private health care agency.
Thursday, November 13, 2014
VA Says Gerigk Being Fired with Three Others
Directors at the VA health care systems in Pittsburgh, central Alabama and Dublin, Georgia, are in the process of being fired, and the VA's deputy chief procurement director in Washington is also in line to lose her job, the VA headquarters in Washington said in recent news releases.
The Pittsburgh move comes almost two years after CNN first reported about an outbreak of Legionnaires' disease at a VA hospital there. Part of CNN's 2012 investigation found 21 patients at the Pittsburgh VA who were diagnosed with the disease, five of whom died within 30 days of being diagnosed.
VA officials knew about problems and dangers with the medical center's water system, but did not disclose that information for almost a year.
In a followup investigation, the VA's inspector general found that the Pittsburgh VA's staff did not take the proper steps to prevent the spread of Legionella, such as flushing water faucets, and that pneumonia patients were not properly tested for the disease.
The director of that hospital, Terry Gerigk Wolf, has been on administrative leave since June and is now in the process of being fired for "conduct unbecoming a Senior Executive." Wolf has the right to appeal that decision before the firing is complete, a VA representative said.
"VA will actively and aggressively pursue disciplinary action on those who violate our values. There should be no doubt that when we discover evidence of wrongdoing, we will hold employees accountable," VA Deputy Secretary Sloan Gibson said.
The firings are a direct result of wrongdoing found by the VA's Office of Inspector General and the Office of Accountability Review, including significant delays and wait times of veterans, manipulation of appointment data, "neglect of duty," inappropriate handling of VA contracts and misconduct at VA facilities.
The firings also follow a yearlong investigation by CNN that found numerous instances of delays in care and, at times, deaths of U.S. veterans at VA facilities across the country. The reports sparked a national outrage, which led to the resignation of VA Secretary Eric Shinseki and prompted numerous House and Senate hearings.
That resulted in a new law revising the VA health care system designed to help veterans get faster care. The new law, which was passed this summer and signed by President Obama, also gives VA Secretary Robert McDonald more authority to quickly fire top executives.
The VA also announced that John Goldman, the director of the VA medical center in Dublin, is in the process of being fired after the VA's inspector general revealed that the hospital's staff closed out more than 1,500 patient appointments to hide long wait times in order to meet goals set by VA headquarters. Goldman announced he was retiring four days before his removal was made public.
U.S. Rep. Jeff Miller, R-Florida and chairman of the House Veterans' Affairs Committee, who led the charge for more accountability at the VA and whose committee has been instrumental in pressing for details of wrongdoing at VA facilities, said Tuesday that he is not certain the new process of firings is enough.
"Bragging about the proposed removal of someone who has already announced his retirement can only be described as disingenuous. Department leaders must not tolerate this instance of what appears to be blatant deceit. Such semantic sleights of hand are insulting to the families struck by the VA scandal and only do more harm to the department's badly damaged credibility," he said in a statement to CNN.
"Congress acted with near unanimity to give the VA secretary greater authority to actually fire failing executives, not just propose removing them. Because this is merely a proposed action, we need to reserve judgment on whether appropriate accountability has been achieved."
Part of CNN's investigation brought national attention to a secret waiting list at the Phoenix VA and to charges by whistleblowers that veterans had died there, waiting for care. All of the charges have been substantiated by the inspector general. Just after those revelations, three top officials at that VA facility, including Director Sharon Helman, were placed on administrative leave and are in the process of being fired. Helman is still being paid.
The VA is also in the process of firing James Talton, the director of the Central Alabama VA Healthcare System, where the inspector general confirmed this year that a lack of trained appointment schedulers contributed to some delays and dysfunction in the hospital's podiatry clinic.
A 2012 inspector general report also found that Central Alabama VA patients did not receive timely colorectal cancer screenings. VA audits this year showed that more than 6,000 patients waited at least 90 days for care at this medical center and that some schedulers there were instructed to hide long wait times.
The fourth VA employee being fired, Deputy Chief Procurement Officer Susan Taylor, inappropriately influenced the awarding of VA contracts to a private company and interfered with an investigation into the matter, according to a report by the VA's inspector general.
Taylor reportedly gave preferential treatment to the company FedBid, an online marketplace, and had an affair with a former employee of several government agencies who had ties to the company.
The VA's inspector general stated that Taylor "improperly disclosed non-public VA information to unauthorized persons, misused her position and VA resources for private gain, and engaged in a prohibited personnel practice."
On Tuesday, the VA also announced that Joan Ricard, the director of the Edward Hines, Jr. VA Hospital in Chicago, will retire at the end of this month, after 40 years at the VA, including two years as director of the hospital.
Ricard has, like other VA officials, been at the center of controversy in recent months. At Hines, like other VA hospitals, CNN and other media outlets reported allegations made by whistle blowers about veterans being kept on secret wait lists, and hiding of actual delays in care, while administrators received bonuses.
The Pittsburgh move comes almost two years after CNN first reported about an outbreak of Legionnaires' disease at a VA hospital there. Part of CNN's 2012 investigation found 21 patients at the Pittsburgh VA who were diagnosed with the disease, five of whom died within 30 days of being diagnosed.
VA officials knew about problems and dangers with the medical center's water system, but did not disclose that information for almost a year.
In a followup investigation, the VA's inspector general found that the Pittsburgh VA's staff did not take the proper steps to prevent the spread of Legionella, such as flushing water faucets, and that pneumonia patients were not properly tested for the disease.
The director of that hospital, Terry Gerigk Wolf, has been on administrative leave since June and is now in the process of being fired for "conduct unbecoming a Senior Executive." Wolf has the right to appeal that decision before the firing is complete, a VA representative said.
"VA will actively and aggressively pursue disciplinary action on those who violate our values. There should be no doubt that when we discover evidence of wrongdoing, we will hold employees accountable," VA Deputy Secretary Sloan Gibson said.
The firings are a direct result of wrongdoing found by the VA's Office of Inspector General and the Office of Accountability Review, including significant delays and wait times of veterans, manipulation of appointment data, "neglect of duty," inappropriate handling of VA contracts and misconduct at VA facilities.
The firings also follow a yearlong investigation by CNN that found numerous instances of delays in care and, at times, deaths of U.S. veterans at VA facilities across the country. The reports sparked a national outrage, which led to the resignation of VA Secretary Eric Shinseki and prompted numerous House and Senate hearings.
That resulted in a new law revising the VA health care system designed to help veterans get faster care. The new law, which was passed this summer and signed by President Obama, also gives VA Secretary Robert McDonald more authority to quickly fire top executives.
The VA also announced that John Goldman, the director of the VA medical center in Dublin, is in the process of being fired after the VA's inspector general revealed that the hospital's staff closed out more than 1,500 patient appointments to hide long wait times in order to meet goals set by VA headquarters. Goldman announced he was retiring four days before his removal was made public.
U.S. Rep. Jeff Miller, R-Florida and chairman of the House Veterans' Affairs Committee, who led the charge for more accountability at the VA and whose committee has been instrumental in pressing for details of wrongdoing at VA facilities, said Tuesday that he is not certain the new process of firings is enough.
"Bragging about the proposed removal of someone who has already announced his retirement can only be described as disingenuous. Department leaders must not tolerate this instance of what appears to be blatant deceit. Such semantic sleights of hand are insulting to the families struck by the VA scandal and only do more harm to the department's badly damaged credibility," he said in a statement to CNN.
"Congress acted with near unanimity to give the VA secretary greater authority to actually fire failing executives, not just propose removing them. Because this is merely a proposed action, we need to reserve judgment on whether appropriate accountability has been achieved."
Part of CNN's investigation brought national attention to a secret waiting list at the Phoenix VA and to charges by whistleblowers that veterans had died there, waiting for care. All of the charges have been substantiated by the inspector general. Just after those revelations, three top officials at that VA facility, including Director Sharon Helman, were placed on administrative leave and are in the process of being fired. Helman is still being paid.
The VA is also in the process of firing James Talton, the director of the Central Alabama VA Healthcare System, where the inspector general confirmed this year that a lack of trained appointment schedulers contributed to some delays and dysfunction in the hospital's podiatry clinic.
A 2012 inspector general report also found that Central Alabama VA patients did not receive timely colorectal cancer screenings. VA audits this year showed that more than 6,000 patients waited at least 90 days for care at this medical center and that some schedulers there were instructed to hide long wait times.
The fourth VA employee being fired, Deputy Chief Procurement Officer Susan Taylor, inappropriately influenced the awarding of VA contracts to a private company and interfered with an investigation into the matter, according to a report by the VA's inspector general.
Taylor reportedly gave preferential treatment to the company FedBid, an online marketplace, and had an affair with a former employee of several government agencies who had ties to the company.
The VA's inspector general stated that Taylor "improperly disclosed non-public VA information to unauthorized persons, misused her position and VA resources for private gain, and engaged in a prohibited personnel practice."
On Tuesday, the VA also announced that Joan Ricard, the director of the Edward Hines, Jr. VA Hospital in Chicago, will retire at the end of this month, after 40 years at the VA, including two years as director of the hospital.
Ricard has, like other VA officials, been at the center of controversy in recent months. At Hines, like other VA hospitals, CNN and other media outlets reported allegations made by whistle blowers about veterans being kept on secret wait lists, and hiding of actual delays in care, while administrators received bonuses.
- “Quite simply, any VA administrator who purposely manipulated appointment data, covered up problems, retaliated against whistleblowers or who was involved in malfeasance that harmed veterans must be fired. Unfortunately, I’m concerned that VA’s implementation of the Veterans Access, Choice and Accountability Act of 2014 may be interfering with this concept. By creating an added appeals process in which VA employees are given advance notice of the department’s plans to fire them, VA appears to be giving failing executives an opportunity to quit, retire or find new jobs without consequence – something we have already seen happen in recent weeks. Right now, it's incumbent on all of VA's external watchdogs — Congress, the press and the American public — to maintain pressure on the department until those who created VA’s problems receive the accountability they are due. This is the only way veterans and families struck by the VA scandal can get the closure they deserve. If any current laws or regulations are impeding the department’s ability to swiftly hold employees accountable, VA leaders must work with Congress so those laws and regulations can be changed.” – Rep. Jeff Miller, Chairman,
Pittsburgh VA Official Finally Fired
By Walter F. Roche Jr.
A top Pittsburgh Veterans Affairs official who already had been placed on leave has finally been formally fired following demands from members of congress that she and other VA officials must be terminated.
Terry Gerigk Wolf, the director of the Pittsburgh VA Health System, had been suspended in June over her role in a fatal Legionnaires Disease outbreak in 2011.
The action comes a month after an internal VA review concluded she should be fired under the provisions of a recently approved statute eliminating procedural roadblocks to the firing of VA officials.
Lawmakers, including U.S. Rep. Jeff Miller, chairman of the House Veterans Affairs Committee, had been calling for Wolf's and other immediate terminations in the wake of multiple investigations highly critical of the care being provided in Veterans Affairs health facilities.
“Given that Wolf’s firing comes two years after the VA Pittsburgh Healthcare System Legionnaires’ disease outbreak ended, it’s obvious VA had no interest in holding her accountable initially and was only driven to this point after intense congressional and media scrutiny, " Flake said in a statement Thursday.
Flake noted that Wolf's former boss, Michael Moreland, was paid a hefty $63,000 bonus even as the fatal Legionnaires outbreak was coming to light. He subsequently resigned and now holds a top position with a national substance abuse treatment provider.
Wolf also was singled out for honors by then VA Secretary Eric Shinseki who cited her in 2010 along with five other VA health officials for providing health care that was "the best of the best."
Six veterans died in the outbreak and 22 were sickened. The outbreak has been attributed to problems in the water systems at Pittsburgh area VA facilities and failure to conduct complete tests on the victims.
The dismissal was disclosed in a brief departmental press release citing substantiated allegations of "conduct unbecoming of a senior executive and wasteful spending."
“This removal action underscores VA’s commitment to hold leaders accountable and get veterans the care they need,” the release concluded.
Flake said, "Though Wolf’s removal is a positive step, VA still has a lot to learn about honesty, integrity and accountability, and this action doesn’t change that fact.”
Wolf is the second high ranking VA official to be discharged amid allegations of poor and delayed care for veterans.
wfrochejr999@gmail.com
A top Pittsburgh Veterans Affairs official who already had been placed on leave has finally been formally fired following demands from members of congress that she and other VA officials must be terminated.
Terry Gerigk Wolf, the director of the Pittsburgh VA Health System, had been suspended in June over her role in a fatal Legionnaires Disease outbreak in 2011.
The action comes a month after an internal VA review concluded she should be fired under the provisions of a recently approved statute eliminating procedural roadblocks to the firing of VA officials.
Lawmakers, including U.S. Rep. Jeff Miller, chairman of the House Veterans Affairs Committee, had been calling for Wolf's and other immediate terminations in the wake of multiple investigations highly critical of the care being provided in Veterans Affairs health facilities.
“Given that Wolf’s firing comes two years after the VA Pittsburgh Healthcare System Legionnaires’ disease outbreak ended, it’s obvious VA had no interest in holding her accountable initially and was only driven to this point after intense congressional and media scrutiny, " Flake said in a statement Thursday.
Flake noted that Wolf's former boss, Michael Moreland, was paid a hefty $63,000 bonus even as the fatal Legionnaires outbreak was coming to light. He subsequently resigned and now holds a top position with a national substance abuse treatment provider.
Wolf also was singled out for honors by then VA Secretary Eric Shinseki who cited her in 2010 along with five other VA health officials for providing health care that was "the best of the best."
Six veterans died in the outbreak and 22 were sickened. The outbreak has been attributed to problems in the water systems at Pittsburgh area VA facilities and failure to conduct complete tests on the victims.
The dismissal was disclosed in a brief departmental press release citing substantiated allegations of "conduct unbecoming of a senior executive and wasteful spending."
“This removal action underscores VA’s commitment to hold leaders accountable and get veterans the care they need,” the release concluded.
Flake said, "Though Wolf’s removal is a positive step, VA still has a lot to learn about honesty, integrity and accountability, and this action doesn’t change that fact.”
Wolf is the second high ranking VA official to be discharged amid allegations of poor and delayed care for veterans.
wfrochejr999@gmail.com
Wednesday, October 22, 2014
Phoenix VA Scheduling Fraud Dates Back a Decade
By Walter F. Roche Jr.
An internal report by the Veterans Affairs Inspector General shows that scheduling fraud to cover up lengthy delays in getting services for veterans at the VA's Phoenix health facility dates back to 2008 and possibly 2004 and the practice was known by top agency officials.
The secret IG report dated Sept. 2, 2008 recounts how staffers at the Arizona facility routinely manipulated appointment requests to make it appear that veterans waited little or no time to see a physician or to get needed services.
The report which was sent to the then director of the Phoenix VA discloses that the staffers were fearful that if the true waiting times were disclosed they would be subject to criticism and possible disciplinary action by their superiors.
"We found that it was accepted past practice at the medical center to avoid wait times greater than 30 days and that employees continue this practice," the report states.
The report states that it was common practice that if a veteran asked in June for an appointment in August, the schedulers would automatically change the request date to the actual August date of the appointment creating the fiction that there was no wait time.
Another Phoenix staffer told the IG that the practice of manipulating appointment requests dated back to at least 2004 when she first went to work there.
Disclosure of the 2008 findings comes amidst recent disclosures of lengthy delays in veterans getting critical life saving care at the Phoenix facility.
U.S. Rep. Jeff Miller, a Florida Republican and chairman of the House Veterans Affairs Committee said the report shows top level VA officials knew about the scheduling errors and sought to keep it secret.
The auditors interviewed a supervisor who worked at the center at the time who corroborated the accounts of the schedulers.
"She (the supervisor) said that they did this to avoid making appointments that showed up on a negative list generated by supervisors that listed appointments with more than a 30.-day wait time. She explained that, in the past, to avoid having her name on the list, she scheduled appointments twice."
The supervisor said the actual request dates were eventually erased to make it appear that the veteran got the requested appointment immediately.
Though the supervisor told auditors she thought the practice had been changed, a scheduler told the inspector general's investigators that she had followed the exact same procedure.
"She (the scheduler) said that she changed one as recently as one hour prior to her interview with us and that they (supervisors) will ding the heck out of you if they see a (wrong) number on the bottom of their report," the IG official wrote.
wfrochejr999@gmail.com
An internal report by the Veterans Affairs Inspector General shows that scheduling fraud to cover up lengthy delays in getting services for veterans at the VA's Phoenix health facility dates back to 2008 and possibly 2004 and the practice was known by top agency officials.
The secret IG report dated Sept. 2, 2008 recounts how staffers at the Arizona facility routinely manipulated appointment requests to make it appear that veterans waited little or no time to see a physician or to get needed services.
The report which was sent to the then director of the Phoenix VA discloses that the staffers were fearful that if the true waiting times were disclosed they would be subject to criticism and possible disciplinary action by their superiors.
"We found that it was accepted past practice at the medical center to avoid wait times greater than 30 days and that employees continue this practice," the report states.
The report states that it was common practice that if a veteran asked in June for an appointment in August, the schedulers would automatically change the request date to the actual August date of the appointment creating the fiction that there was no wait time.
Another Phoenix staffer told the IG that the practice of manipulating appointment requests dated back to at least 2004 when she first went to work there.
Disclosure of the 2008 findings comes amidst recent disclosures of lengthy delays in veterans getting critical life saving care at the Phoenix facility.
U.S. Rep. Jeff Miller, a Florida Republican and chairman of the House Veterans Affairs Committee said the report shows top level VA officials knew about the scheduling errors and sought to keep it secret.
“Make
no mistake. The department’s data manipulation scandal was caused by
selfish VA bureaucrats who lied in order to hide interminable waits for
medical care," he said, adding that the inspector general "missed the forest for the
trees, often labeling what we now know to be systemic and willful
manipulation of medical care appointment data as basic
procedural problems and breakdowns in training.
The 2008 report states, "Two medical center schedulers told us that it was common practice to
alter appointments to obtain 0-days wait time to avoid wait times
greater than 30 days."The auditors interviewed a supervisor who worked at the center at the time who corroborated the accounts of the schedulers.
"She (the supervisor) said that they did this to avoid making appointments that showed up on a negative list generated by supervisors that listed appointments with more than a 30.-day wait time. She explained that, in the past, to avoid having her name on the list, she scheduled appointments twice."
The supervisor said the actual request dates were eventually erased to make it appear that the veteran got the requested appointment immediately.
Though the supervisor told auditors she thought the practice had been changed, a scheduler told the inspector general's investigators that she had followed the exact same procedure.
"She (the scheduler) said that she changed one as recently as one hour prior to her interview with us and that they (supervisors) will ding the heck out of you if they see a (wrong) number on the bottom of their report," the IG official wrote.
wfrochejr999@gmail.com
Thursday, October 16, 2014
Review Finds Multiple Faults at Nashville, York VA
By Walter F. Roche Jr.
An inspector general's report on U.S. Veterans Affairs facilities in Nashville and York has found multiple serious deficiencies in the care provided to veterans including the failure to adequately review surgical procedures resulting in death.
The report from the VA Office of Inspector General issued Thursday also found that the care provided to severe stroke victims did not meet expected standards primarily due to the complete lack of a stroke management policy.
At York, auditors found, three veterans suffering acute strokes were not considered for transfer to a stroke specialty facility due to the lack of a set policy for doing so.
In the review of surgical procedures, the report states, "Several surgical deaths that occurred from January to June of 2013 had identified problems or opportunities for improvement. There was no evidence that the morbidity and mortality committee reviewed one of those deaths."
Other deficiencies in stroke care included failure to screen 12 of 26 patients in Nashville and five of nine in York for swallowing difficulties before they were fed.
The audit covered fiscal 2013 and the first eight months of 2014 and the findings were not disputed by the VA. The agency also agreed to corrective actions recommended by the inspector general.
The two facilities were praised for the care provided by telephone consultations, but in many other areas deficiencies were noted.
For instance so-called peer reviews of cases over a six month period had not been reported to an oversight panel in 20 of 28 cases. Six focused reviews of physicians' performances had not been reported to the Medical Executive Board, the panel that issues credentials to physicians.
Reviews required in cases where cardio-pulmonary resuscitation was used were not performed and a surgical quality review committee had met only two times over six months.
Minutes of the meetings of the executive board "did not reflect sufficient discussion of corrective action and tracking of events to closure," the audit states.
Electronic medical records both at York and Nashville did not include discharge instructions in nine cases and five patients did not receive "services or items ordered for them within the prescribed time frame."
An inspector general's report on U.S. Veterans Affairs facilities in Nashville and York has found multiple serious deficiencies in the care provided to veterans including the failure to adequately review surgical procedures resulting in death.
The report from the VA Office of Inspector General issued Thursday also found that the care provided to severe stroke victims did not meet expected standards primarily due to the complete lack of a stroke management policy.
At York, auditors found, three veterans suffering acute strokes were not considered for transfer to a stroke specialty facility due to the lack of a set policy for doing so.
In the review of surgical procedures, the report states, "Several surgical deaths that occurred from January to June of 2013 had identified problems or opportunities for improvement. There was no evidence that the morbidity and mortality committee reviewed one of those deaths."
Other deficiencies in stroke care included failure to screen 12 of 26 patients in Nashville and five of nine in York for swallowing difficulties before they were fed.
The audit covered fiscal 2013 and the first eight months of 2014 and the findings were not disputed by the VA. The agency also agreed to corrective actions recommended by the inspector general.
The two facilities were praised for the care provided by telephone consultations, but in many other areas deficiencies were noted.
For instance so-called peer reviews of cases over a six month period had not been reported to an oversight panel in 20 of 28 cases. Six focused reviews of physicians' performances had not been reported to the Medical Executive Board, the panel that issues credentials to physicians.
Reviews required in cases where cardio-pulmonary resuscitation was used were not performed and a surgical quality review committee had met only two times over six months.
Minutes of the meetings of the executive board "did not reflect sufficient discussion of corrective action and tracking of events to closure," the audit states.
Electronic medical records both at York and Nashville did not include discharge instructions in nine cases and five patients did not receive "services or items ordered for them within the prescribed time frame."
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