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Press Release
VA Office of Inspector General Releases Administrative Investigation Report Concerning John Thomas Burch, Jr.
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VA employee used position for private gain and misused government resources connected to outside employment with veterans’ charity.
Press Release
VA Office of Inspector General Releases Phoenix Consult Mismanagement Report
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OIG review finds that the Phoenix VA Health Care System inappropriately discontinued consults for some patients in 2015.
Special Publication
OIG Monthly Highlights
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Read about our top reports and investigations in December 2016 OIG REPORTS Review of Antimicrobial Stewardship Programs in Veterans Health Administration Facilities As directed by the Senate Appropriations Committee report to accompany H.R. 2029, Military Construction, Department of Veterans Affairs, and Related Agencies Appropriation Bill 2016, and at the request of Senator Dianne Feinstein, the Office of Inspector General (OIG) reviewed Veterans Health Administration (VHA) implementation of Antimicrobial Stewardship Programs (ASPs). The majority of VHA facilities had established ASPs; however, OIG identified variations with program implementation. A large majority of facilities had written policies and designated ASP champions; however, over one third did not timely complete program evaluation, and facilities reported less than 50 percent compliance with staff education on appropriate use of antibiotics. VHA made efforts to collect and analyze data on antibiotic use and resistance but did not endorse one standard data collection tool for inter-facility comparisons and consistency of data collection and reporting. Additionally, facilities did not consistently generate clinical outcome reports on antibiotic usage. Therefore, VHA cannot effectively measure positive or negative national trends on antibiotic use to guide improvement efforts. With standardization, individual facility and system-wide trends can be analyzed. Further, in order to achieve optimal ASPs, facility leaders need to provide dedicated staff, administrative support, and essential tools to develop and maintain such programs. OIG recommended that the Under Secretary for Health implement procedures to ensure that facilities comply with VHA Directive 1031 requirements, including the completion of annual evaluations, designation of provider and pharmacy champions, staff education, and the provision of adequate dedicated staffing and resources; require VHA facilities to track and generate clinical outcome reports on antibiotic use; and consider implementing standardized tools and definitions for antimicrobial stewardship data and a uniform reporting system to permit analysis of comparable information over time.
Oversight Report
Review of the Implementation of the Veterans Choice Program
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We conducted this review at the request of Senator Johnny Isakson, Chairman of the Senate Committee on Veterans’ Affairs, who expressed concerns about the implementation of the Veterans Choice Program (Choice) and the barriers facing veterans trying to access it. Our review focused on whether veterans were experiencing barriers accessing Choice during its first year of implementation. Choice, as part of the Patient Centered Community Care (PC3) Program, provided care for eligible veterans, when the local VHA medical facilities lack available specialists, have long wait times, or are geographically inaccessible. We reviewed monthly reports to identify average wait times for multiple stages of the Choice process, including the authorization of care, scheduling, and the delivery of health care to veterans. We determined several barriers exist in accessing care through Choice, to include cumbersome authorization and scheduling procedures, inadequate provider networks, and potential veteran liability for treatment costs. After being scheduled with a Choice provider, on average the veteran waited about 13 days to receive care. VHA identified approximately 1.2 million instances in which veterans could not receive VHA appointments from November 1, 2014 through September 30, 2015. During this period, about 283,500 eligible veterans opted into Choice, and 149,000 of these received an appointment with a Choice provider. We calculated a 13 percent rate of Choice utilization (based on appointments provided compared veteran eligible to receive care). We were unable to determine why the other 87 percent did not access Choice. We recommended the Under Secretary for Health streamline procedures for accessing care, develop accurate forecasts of demand for care in the community, reduce providers’ administrative burdens, ensure veterans are not liable for authorized care, and ensure provider payments are made in a timely manner. The Under Secretary for Health concurred with our findings and recommendations.
Oversight Report
Review of Alleged Human Resources Delays at the Atlanta VA Medical Center
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VA OIG received and substantiated allegations that the Atlanta VA Medical Center had a backlog of over 300 unadjudicated background investigations and that mandatory drug testing of new hires did not occur for 6 months. VA officials confirmed the VAMC had a backlog of unadjudicated background investigations by mid FY 2015. The Director of VA Central Office’s Personnel Security and Suitability Service said the VAMC had a backlog of about 200 of these investigations as of July 2015. Atlanta HR personnel acknowledged a backlog dating as far back as 2012. Even though the lack of available records limited our ability to quantify the extent of the backlog, we substantiated that backlogs were occurring by determining that the average adjudication processing time at the VAMC was about 170 days. We also substantiated that the Drug Free Workplace Program was not administered from November 2014 to May 2015. These lapses occurred because records within the personnel security program were inadequate, policies were not implemented as required, and HR staff were not adequately trained. VAMC management did not ensure the continuity of the DFWP when the former coordinator left the position in September 2014. Without proper controls over these functions, the VAMC cannot reliably attest to the suitability of its staff, exposing veterans and employees to individuals who have not been properly vetted. The facility lacks assurance that employees in Testing Designated Positions remain suitable for employment. We recommended the Medical Center Director assess the HR program and ensure staff receive appropriate background investigations, provide training on the requirements of the personnel security program, and monitor the DFWP. The Director concurred with our recommendations. We consider the corrective action plans the facility submitted acceptable and will follow up on their implementation.
Oversight Report
Review of Alleged Improperly Sole Sourced Ophthalmology Service Contracts at the Phoenix VA Health Care System
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OIG reviewed this complaint alleging that the PVAHCS improperly sole-sourced ophthalmology contracts to Barnet Dulaney Perkins, and the Chief of Staff and Interim Associate Director had a conflict of interest with BDP. We did not substantiate that the PVAHCS improperly sole-sourced ophthalmology service contracts to BPD, but found that the PVAHCS and NCO 18 used full and open competition to award BPD three ophthalmology service contracts valued at just over $30.4 million, respectively, on February 1, 2006 and October 1, 2009. However, NCO 18 contracting officer did not properly maintain contract documentation in eCMS for two contracts. The PVACHS’s issuance of just over $12.4 million in unauthorized commitments to BDP and the lack of recruitment of VA ophthalmologists may have made it appear that these contracts had been sole-sourced. We did not substantiate the allegation of a conflict of interest between the named PVACHS officials and BDP because we found no evidence that a business, financial, and/or personal relationship existed between them and BDP. The PVAHCS officials had pressured the contracting officer to sole-source additional contracts to BDP because of concerns over possible delays in care and lapses in the continuity of care, but the contracting staff did not give into the pressure, and the PVAHCS began using VA’s PC3 contracts in March 2015. We recommended the Service Area Office West Director ensure the proper maintenance of contracting files and the PVAHCS Director ratify the unauthorized commitments and develop a business case for the provision of ophthalmology services. The NCO 18 provided contract documents almost one year after the start of the review that showed NCO 18 properly awarded the contracts and the first allegation was unsubstantiated. The PVAHCS and SAOW Directors agreed with the recommendations and provided responsive action plans.
Oversight Report
Review of Alleged Waste of Funds on a Cloud Brokerage Service Contract
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In January 2015, the VA Office of Inspector General (OIG) received an anonymous Hotline complaint alleging that the Office of Information and Technology (OI&T) spent over $2 million on a cloud brokerage service contract that provided only limited brokerage functionality and that VA’s actions did not ensure adequate system performance or return on investment. We substantiated that OI&T spent over $2 million on a cloud brokerage service contract that provided limited brokerage functionality and that VA’s actions did not ensure adequate system performance or return on investment. We determined total project costs exceeded $5 million and the system’s limited brokerage service functionality prevented it from being used in a production environment. The project manager did not ensure that formal testing and acceptance were conducted on project deliverables. Project management was not performed in accordance with established procedures and the Project Management Accountability System (PMAS) was not used to hold project managers accountable for meeting project goals. These deficiencies occurred because of a lack of executive oversight and ineffective project management. Without enforcement of oversight controls, project leadership cannot ensure the value of contract deliverables or demonstrate an adequate return on investment for the project. We recommended that the Assistant Secretary for Information and Technology implement improved controls to ensure effective oversight of information technology projects and compliance with information technology project management procedures. Additionally, the Assistant Secretary should enforce the use of the Veteran-focused Integration Process on all software development projects and ensure all VA developed software costs are funded with Information Technology Systems appropriations.