VA OIG
1997
Following a joint investigation by the VA and Department of Health and Human Services (HHS)OIGs and the Postal Inspection Service, the owner and president of an ambulance company pleadedguilty to four counts of mail fraud, and was subsequently sentenced to 63 months’ in prison, over $1million in restitution, and three years’ probation. The guilty plea was the result of a 20-countindictment, which charged that the ambulance service owner contrived a scheme to systemicallydefraud VA and other Government agencies by submitting false claims for payment utilizing theU.S. mail. He generated false billings by inflating billings for transporting patients by his ambulancecompany. Loss to the Government exceeded $2 million. As described in the prior section on postaward reviews of FSS contracts, a $3 million consentjudgment was entered against a medical supply corporation and its three employee owners. Theindividuals acknowledged liability under the False Claims Act for submission of false and fraudulentbillings on Government contracts. The corporation and one of the individuals voluntarily agreed topermanent exclusion from Government contracting and programs, including Medicare andMedicaid. Judgment was entered against a second individual in the amount of $40,000; thisindividual agreed voluntarily to exclusion from Government contracting and programs for a periodof 5 years. The third individual agreed voluntarily to exclusion from Government contracting andprograms for a period of 3 years. The former owner/operator of a company that provided hand tools, machine tools and hardware toVAMCs was extradited from a prison in Rome on behalf of VA and the Department of Defense(DoD), and placed in the custody of a state Division of Criminal Justice to face outstanding charges.The individual was subsequently placed in the custody of VA and DoD OIG special agents to appearin court on an outstanding 19-count indictment charging the individual with bribery and conspiracyto defraud the United States. An earlier joint VA and DoD OIG investigation revealed that, over a4-year period, the individual conspired to pay bribes to VA officials to influence the awarding of 190Government contracts for supplies and services valued at approximately $132,000.
MEDICAL CARE PROGRAMS
1. RESOURCE UTILIZATION
Issue: Pathology and Laboratory Medicine Service (PLMS) Mobile Laboratory (Mobile Lab)
Initiative
Conclusion: Resources for mobile laboratories were not used as intended.
Impact: Reassignment of $5.2 million in unused equipment to other facilities.
Mobile Lab is a cart with eight testing instruments which can be moved throughout a hospital to
perform the 25 most commonly ordered lab tests. It was developed and implemented at selected
VAMCs in FY 1994 at a cost of $20.7 million. We conducted an audit of the Mobile Lab initiative to
determine whether Mobile Lab implementation was performed in a cost-effective manner that ensured
optimal utilization of funding and equipment.
Our review found that the Mobile Lab was not widely used because the instrument configuration on the
cart was selected without consideration of the specific needs of individual laboratory operations and
VAMCs had difficulty determining the best use for Mobile Lab. As a result, over $5 million was spent
on equipment that was never used, and another $5 million provided for the Mobile Lab initiative was
spent for other uses. We recommended that VHA reassign the unused equipment to facilities or
activities that can utilize it. The Under Secretary concurred with the findings and established a task
force to review all viable options to reassign the unused equipment.
(Pathology and LaboratoryMedicine Service (PLMS) Mobile Laboratory Initiative)
Issue: Alleged Inadequate or Inattentive Care of Two Patients
Conclusion: Clinicians had provided appropriate care to one patient, but had not been
sufficiently aggressive in recognizing and following up on the other’s medical needs.
Impact: Improved procedures to prevent recurrence.
We reviewed allegations that medical center clinicians did not provide attentive care for a Nursing
Home Care Unit (NHCU) patient’s respiratory distress, causing him to have unnecessary difficulty
breathing, and that physicians did not properly respond to a psychiatry patient’s lethargic condition,
resulting in his ultimate death.
We concluded that clinicians had reacted properly and adequately treated the NHCU patient’s
respiratory condition. A clinician peer review had been conducted to determine whether the psychiatry
patient’s care had been appropriate. The review concluded that medical and psychiatric care providers
should have ordered neurological and laboratory tests and been more aggressive in monitoring the
patient’s condition. We agreed with these conclusions and found that medical center managers had
initiated appropriate corrective actions to ensure similar instances would not reoccur. They had not,
however, discussed the facts of the psychiatry patient’s care with their Regional Counsel office to
determine the propriety of advising the patient’s family of their prerogative to pursue VA benefits or file
a tort claim, and we recommended that they do so. The Director agreed to obtain Regional Counsel
advice. (
Inspection of Alleged Inadequate Care and Nursing Incompetence on the NHCU, Departmentof Veterans Affairs Medical Center Bronx, NY)
Issue: Alleged Poor Care and Disregard for a Patient’s Advance DirectiveConclusion: Clinicians provided the patient with appropriate treatment for a terminalcondition, but an uninformed clinician did not comply with the patient’s wishes for end-of-lifecare.Impact: Re-emphasis on compliance with advance directive policy to prevent recurrence.We reviewed allegations that clinicians did not provide proper care for a patient who had a terminalheart condition and failed to comply with both the patient’s and spouse’s wishes that all necessarymeasures be pursued to keep the patient alive.We found that clinicians had energetically and conscientiously sought to treat the patient’s terminalheart condition even though they were fully aware that treatment could not improve the patient’scondition or extend his life. Clinicians took great pains to keep both the patient and his spouseinformed of his treatment progress and his ultimately poor prognosis, but both individuals wantedclinicians to exert heroic efforts when the patient needed resuscitation. Unfortunately, the patient’scondition rapidly deteriorated during a tour of duty when the physician on duty was not familiar with hiscase or the family’s desires for heroic measures. Using his clinical judgment, and based on the patient’s
clinical presentation, the physician on duty did not carry through with extensive resuscitative measures
and the patient died.
We recommended that the VAMC Director take action to review the resuscitation and advance
directives policies with medical center physicians and nursing employees in order to clarify the need to
honor patients’ requests, and adhere to established policies. We also recommended that local clinicians
refer similar cases to the medical center’s Ethics Committee for clarification and discussion of the most
appropriate way to manage similar end-of-life wishes of future patients.
The Medical Center Director concurred with our recommendations and provided action plans that
should improve the treatment process. Medical center managers also offered numerous referrals within
the community to assist the patient’s spouse in working through her grieving process.
(Inspection ofAlleged Poor Quality of Care and Disregard of Patient’s Advance Directive for Life-Saving Measures
at the Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA)
Issue: Alleged Inadequate Spinal Cord Injury Unit (SCIU) Clinical and Management Practices
Conclusion: Medical center managers needed to focus on and define the SCIU’s mission in order
to ensure more consistent patient care for patients with chronic spinal cord injuries.
Impact: Reassessment of SCIU mission and staffing to better focus on patient needs.
In response to a VHA request, we conducted an independent inspection to further evaluate earlier VHA
reviews that were conducted to review allegations of alleged patient abuse, instances of improper
relationships between SCI patients and SCIU clinicians, and unprofessional activities among some
clinical employees. We conducted the inspection in collaboration with VHA’s Office of Medical
Inspector, and convened a panel of nationally recognized SCI treatment experts in order to fully
evaluate all aspects of this highly specialized treatment program. The panel developed independent
findings and recommendations which we agreed with and which supported our findings.
We were unable to substantiate any of the allegations, but concluded that actions were needed to
improve the quality of care for SCI patients. We found that medical center managers had initiated
several measures to improve the SCI treatment process before our inspection began. Managers had
reassigned ten employees to other areas of the medical center and began recruiting for qualified
replacements, developed an effective cross-training program for all SCIU employees so that each
employee was capable of managing more than one function, and established round-the-clock security.
Managers and clinicians had also begun to deliberate on ways to bolster the interdiscisciplinary
treatment team process, and to streamline the quality improvement team concept.
We made the following recommendations:
·
assess the appropriateness of the SCIU’s current mission in order to focus staff energies onacute care/rehabilitation,
·
in concert with the mission reassessment, re-evaluate staffing needs to reflect the treatmentneeds of the ultimate patient population,
strengthen medical record documentation of the treatment process, more actively involve employees in the SCIU performance improvement program, strengthen the interdisciplinary treatment team approach and patient care planning byrequiring more active involvement by all team members, and comprehensively assess SCIU employee training needs in order to strengthen all SCIUpatient care programs.The Medical Center Director concurred with the recommendations and provided implementation plansand actions that properly responded to the issues. (Inspection of Selected Clinical Aspects of the SpinalCord Injury Unit at the Department of Veterans Affairs Medical Center Hampton, VA)Issue: Alleged Improper Clinical Privileges and Resulting Patient HarmConclusion: Local clinical managers did not adequately evaluate or validate a surgeon’s training andexperience and improperly awarded plastic surgery privileges.Impact: Assurance of properly skilled physician treatment.We reviewed allegations that medical center clinical managers had improperly awarded plastic surgeryprivileges and a plastic surgery fellowship position to a surgeon who did not have the requisite trainingor experience to qualify him to perform the functions of that position. The complainants also assertedthat unnamed patients had been harmed in some way because the surgeon did not know what he wasdoing.We found that the surgeon had sought a position as a plastic surgery fellow, and had requested surgicalprivileges to perform a wide range of plastic surgery procedures. He provided medical center clinicalmanagers with a resume of the experience and training that he believed qualified him for the position.He asserted that much of the applied surgical experience had been received in a foreign country andcould not be readily validated. Clinical managers accepted his credentials at face value and did notpersonally validate any of the information as required by VA policy. When nursing employees began toquestion the surgeon’s skills, clinical managers reassessed the surgeon’s qualifications and rescinded hisprivileges. He was subsequently terminated from his fellowship position. Multiple clinical reviews ofhis patients’ medical records failed to elicit any evidence that the surgeon had in any way harmed anypatients.We recommended that the medical center strengthen its credentialing and privileging procedures byensuring that the Chief of Staff or designee personally verify and validate reported experience andtraining. The Director concurred with our recommendation and initiated appropriate corrective actions.(Inspection of Alleged Misrepresentation of Medical Credentials at a Department of Veterans AffairsMedical Center)
This page was last updated on 10/05/2007 01:01 PM
The information on this web site is designed to encourage a discussion about Veterans Administration medical malpractice, malpractice claims and procedures. It is not intended to be legal advice. Legal advice can only be obtained from an attorney. If you have a medical malpractice claim against the Veterans Administration, you should consult with an attorney who is familiar with handling medical malpractice claims against the Veterans Administration and the Federal Tort Claims Act.
In the event that you have a Veterans Administration medical malpractice claim, you should immediately seek representation from an attorney who is experienced with litigating medical malpractice cases against the Veterans Administration or the VA.
This site contains information on va malpractice, veteran administration medical malpractice and veteran administration medical malpractice attorneys and lawyers. Web site for information on va malpractice claim and va medical malpractice claims as well as veterans administration patient safety issues. Information on medical malpractice at the VA, Veterans Administration medical errors, legal representation for medical errors