Release of Administrative Closures03/16/2015 08:00 PM EDT

April 16th, 2015

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03/16/2015 08:00 PM EDT


As a result of a review of Office of Inspector General decision-making practices on closing reviews administratively, the Deputy Inspector General instituted a new policy requiring coordination of administrative closures within the Immediate Office of the Inspector General, the Office of Counselor to the Inspector General, and the Release of Information Office.

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Healthcare Inspection – Alleged Lack of Timeliness and Quality of Care Concerns at the Memphis VA Medical Center, Memphis, Tennessee04/15/2015 08:00 PM EDT

April 16th, 2015

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04/15/2015 08:00 PM EDT


OIG conducted an inspection in response to complaints about the timeliness and quality of care in the Emergency Department (ED) and Primary Care of the Memphis VA Medical Center (facility), Memphis, TN, which is part of Veterans Integrated Service Network 9. We did not substantiate the allegation that Memphis ED personnel were inattentive and failed to provide timely care. The patient was triaged appropriately on arrival. The 4-hour delay the patient experienced before leaving without being seen by an ED provider was unfortunate yet unavoidable due to the patient population in the ED at the time of the patient’s visit. We did not substantiate the allegation that Primary Care provider assistants were inattentive to the patient’s requests for medical help via phone and VA’s electronic secure messaging system. Primary Care clinic staff responded to the patient’s requests, and the patient received the services he requested. While we found occasional delays in responding to the patient’s requests, overall, delays were not typical. We substantiated the allegation that VA refused to pay for private facility care; however, this decision was based on Federal regulations. We substantiated the allegation that the facility faxed incorrect records to the ED of a private hospital. This was attributed to human error by a staff member at the facility, and as a result, the facility changed its process for providing medical information to other hospitals. We found that the new process was being followed at the time of our visit; therefore, we made no recommendation. We did not substantiate the allegation that the facility ignored recommendations or postponed implementation of actions recommended by the OIG in previous reports. We made no recommendations.

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Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Veterans Health Care System of the Ozarks, Fayetteville, Arkansas04/15/2015 08:00 PM EDT

April 16th, 2015

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04/15/2015 08:00 PM EDT


The VA Office of Inspector General conducted a review of the Veterans Health Care System of the Ozarks’ Community Based Outpatient Clinics (CBOCs) and other outpatient clinics to evaluate for safe, consistent, and high-quality health care. The review evaluated the clinics’ compliance with selected VHA requirements for alcohol use disorder, human immunodeficiency virus (HIV) screening, and outpatient documentation. We also randomly selected the Jay, OK, CBOC as a representative site and evaluated the environment of care on February 9, 2015. OIG noted opportunities for improvement and made six recommendations in the following focused review areas: Alcohol Use Disorder, HIV Screening, and Environment of Care.

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Combined Assessment Program Review of the Martinsburg VA Medical Center, Martinsburg, West Virginia04/15/2015 08:00 PM EDT

April 16th, 2015

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04/15/2015 08:00 PM EDT


The VA Office of Inspector General (OIG) conducted a review to evaluate selected health care facility operations, focusing on patient care quality and the environment of care. During the review, OIG provided crime awareness briefings to 47 employees. This review focused on nine operational activities. The facility complied with selected standards in the following two activities (1) coordination of care and (2) magnetic resonance imaging safety. The facility’s reported accomplishments were receiving national recognition and distinction from The Joint Commission’s Top Performer on Key Quality Measures® program and receiving the Marsha Goodwin-Beck Award for Excellence in Geriatric Leadership. OIG made recommendations for improvement in the following seven activities: (1) quality management, (2) environment of care, (3) medication management, (4) acute ischemic stroke care, (5) surgical complexity, (6) emergency airway management, and (7) Mental Health Residential Rehabilitation Treatment Program.

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Review of Alleged Data Manipulation and Mismanagement at VA Regional Office Philadelphia, PA04/14/2015 08:00 PM EDT

April 15th, 2015

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04/14/2015 08:00 PM EDT


In late May 2014, the VA Office of Inspector General (OIG) began receiving a number of allegations through the VA OIG Hotline of mismanagement at the Philadelphia Regional Office (VARO). Many of these allegations included indicators that staff had a serious mistrust of VARO management. On June 19, 2014, VA OIG benefits inspectors, auditors, and criminal and administrative investigators began a comprehensive review of conditions at the Philadelphia VARO. Overall, OIG staff conducted over 100 interviews with VARO management and staff to assess the merits of multiple allegations of wrongdoing. We substantiated serious issues involving mismanagement and distrust of VARO management impeding the effectiveness of its operations and services to veterans. Overall, OIG made 35 recommendations for improvement at the Philadelphia VARO, encompassing mismanagement of VA resources resulting in compromised data integrity, lack of financial stewardship, and lack of confidence in management’s ability to effectively manage workload, to include mail management and in protecting documents containing personally identifiable information. There is an immediate need to improve the operation and management of this VARO and take actions to ensure a more effective work environment. Further, the extent to which management oversight has been determined to be ineffective and/or lacking requires VBA’s oversight and action. It is imperative to ensure VBA leadership and the VARO Director implement plans to ensure the unprocessed workload we identified is processed and to provide appropriate oversight that is critical to minimizing the potential future financial risk of making inaccurate benefit payments. This includes maintaining oversight needed to ensure all future workload is processed timely and in ensuring the accurate and timely delivery of benefits and services.

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Review of Alleged Data Manipulation at VA Regional Office, Boston, Massachusetts04/14/2015 08:00 PM EDT

April 15th, 2015

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04/14/2015 08:00 PM EDT


We substantiated that the Veteran Services Officer (VSO), accredited and employed by the Veterans Of Foreign Wars (VFW), Department of Massachusetts, manipulated or attempted to manipulate dates of claims at the Boston VA Regional Office. We also found evidence indicating the VSO may have engaged in a similar manipulation scheme at the VARO in Togus, Maine. The VSO secretly date stamped multiple blank documents, providing the opportunity to cut, attach, and photocopy these dates onto claims documents for other claimants. Manipulation of dates of claims appeared to be a routine practice dating back to at least July 2013. We found about 25 benefits claims in the VSO’s workspace that had not been submitted to the VARO for processing; some of the claims dated back to October 2013. We could not identify claims where the VSO may have altered the actual dates of claim because there is no audit trail that tracks claims submitted by individual VSOs. Untimely processing by the VSO impedes the VARO’s ability to initiate required development actions and results in veterans waiting longer for their claim to be processed. The VSO was able to manipulate dates of claims to cover up the untimely submission of claims because VARO management did not ensure only authorized staff accessed and used its date stamping equipment. Additionally, VARO management did not ensure the keys needed to unlock and operate date stamping machines were securely stored. Rather, keys were stored in unlocked desk drawers near the date stamping machines. Further, manipulation of dates of claims compromised the data integrity of claims processing timeliness and introduced delays in processing benefits claims. We recommended the Under Secretary for Benefits implement plans to ensure only authorized staff at the Boston VARO use date stamping equipment and that they receive refresher training on securing date stamping equipment.

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Administrative Investigation, Improper Access to the VA Network by VA Contractors from Foreign Countries, Office of Information and Technology, Austin, TX04/12/2015 08:00 PM EDT

April 15th, 2015

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04/12/2015 08:00 PM EDT


Seven years after the 2006 data breach, VA information security employees still reacted with indifference, little sense of urgency, or responsibility concerning a possible cyber threat incident. Austin Information Technology Center (AITC) OIT employees failed to follow VA information security policy and contract security requirements when they approved VA contractor employees to work remotely and access VA’s network from China and India. One accessed it from China using personally-owned equipment (POE) that he took to and left in China, and the other accessed it from India using POE that he took with him to India and then brought back to the United States (US). After the Acting CIO learned of this improper remote access, he gave verbal instructions for it to cease; however, VA information security employees at all levels failed to quickly respond to stop the practice and to determine if there was a compromise to any VA data as a result of VA’s network being accessed internationally. Further, we found that a VA employee, as well as other VA contractor employees, improperly connected to VA’s network from foreign locations.

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Administrative Investigation, Improper Access to the VA Network by VA Contractors from Foreign Countries, Office of Information and Technology, Austin, TX04/12/2015 08:00 PM EDT

April 15th, 2015

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04/12/2015 08:00 PM EDT


Seven years after the 2006 data breach, VA information security employees still reacted with indifference, little sense of urgency, or responsibility concerning a possible cyber threat incident. Austin Information Technology Center (AITC) OIT employees failed to follow VA information security policy and contract security requirements when they approved VA contractor employees to work remotely and access VA’s network from China and India. One accessed it from China using personally-owned equipment (POE) that he took to and left in China, and the other accessed it from India using POE that he took with him to India and then brought back to the United States (US). After the Acting CIO learned of this improper remote access, he gave verbal instructions for it to cease; however, VA information security employees at all levels failed to quickly respond to stop the practice and to determine if there was a compromise to any VA data as a result of VA’s network being accessed internationally. Further, we found that a VA employee, as well as other VA contractor employees, improperly connected to VA’s network from foreign locations.

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Healthcare Inspection – Lapses in Access and Quality of Care, VA Maryland Health Care System, Baltimore, Maryland04/13/2015 08:00 PM EDT

April 15th, 2015

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04/13/2015 08:00 PM EDT


OIG conducted a review in response to concerns raised by Senator Barbara Mikulski regarding lapses in access and quality of care issues at the VA Maryland Health Care System. The purpose of this review was to determine the extent to which those concerns had merit. We substantiated delayed access for a patient at the Perry Point campus and identified some contributing factors, including insufficient primary care provider staffing. We substantiated that the system experienced challenges in providing timely access to orthopedic surgical services but had developed an action plan to address these issues prior to our visit. We did not substantiate concerns that a second patient experienced delays in service delivery or cancer diagnosis at the urgent care center at Perry Point. We also did not substantiate allegations related to a third patient’s diabetes and diabetic neuropathy pain; however, we found that community health care information was not included in the patient’s electronic health record because of provider documentation lapses and, possibly, a backlog of documents waiting to be scanned. We further found that the system’s policy for tube-feeding nutrition did not comply with all requirements. We made nine recommendations.

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Administrative Investigation, Improper Access to the VA Network by VA Contractors from Foreign Countries, Office of Information and Technology, Austin, TX04/12/2015 08:00 PM EDT

April 13th, 2015

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04/12/2015 08:00 PM EDT


VA OIG Administrative Investigations Division issued a report titled: Administrative Investigation, Improper Access to the VA Network by VA Contractors from Foreign Countries, Office of Information and Technology, Austin, TX

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