The Eagle Review - Federal

San Antonio Veterans Affairs Goes Through OIG Inspection

PLEASE NOTE: Nothing in this publishing or on this website should be taken as legal advice.

San Antonio Veterans Affairs Goes Through OIG Inspection

The Veterans Affairs Office of Inspector General completed its “Comprehensive Healthcare Inspection of the South Texas Veterans Health Care System in San Antonio.” Report 22-00040-115. It was completed on May 17, 2023.

The inspection focused on five areas of clinical and administrative operations. The areas included leadership and organizational risks; quality, safety, and value; medical staff privileging; environment of care; and mental health. The mental health review focused on the emergency department and urgent care center.

The inspection was considered unannounced. It occurred during the week of February 7, 2022. The inspection consisted of interviews and reviews of clinical and administrative processes.

Ultimately, the OIG recommended three areas of improvement related to leadership and organizational risk, medical staff privileging, and mental health.

The OIG specifically states the number of recommendations should not be used as a gauge for overall quality of care provided by the health care system.

The Veterans Integrated Service Network Director (VISN) and Executive Director agreed with OIG’s inspection findings and recommendations. They provided an acceptable improvement plan, per the OIG.

Recommendation 1 – Leadership and Organizational Risks

The health care system was recommended to determine the reason it was noncompliant with institutional disclosures.

[A]n institutional disclosure is “a formal process by which VA medical facility leader(s), together with clinicians and others as appropriate, inform the patient or the patient’s personal representative that an adverse event has occurred during the patient’s care that resulted in, or is reasonably expected to result in, death or serious injury, and provide specific information about the patient’s rights and recourse.

Page 10 of the Comprehensive Healthcare Inspection of the South Texas Veterans Health Care System in San Antonio, REPORT #22-00040-11, Dated May 17, 2023

The OIG found leaders did not always complete the institutional disclosure for events which may have contributed to a patient’s death. The impact may hinder trust patients have with the health care system.

Recommendation 2 – Medical Staff Privileging

The health care system was recommended to determine why it was noncompliant with Ongoing Professional Practice Evaluations (OPPE) when reprivileging providers.

An OPPE, per The Joint Commission, identifies professional practice trends that could impact quality and safety of those under care. It also applies to all practitioners granted privileges. The review indicated some of the licensed independent practitioners (LIP) did not have service-specific data which resulted in incomplete data to support the supervisors recommendation to continue the privileges of the provider.

Recommendation 3 – Mental Health

The health care system was recommended to determine why it was noncompliant with follow-up for those released from the hospital that were deemed to be safe to discharge from the emergency department after a positive suicide screening was determined. Out of the patients selected by the OIG, four fell into this category. The OIG indicated the health care system was not following proper procedures to assure continuity in care for the patient until the next mental health session through outpatient, inpatient, or in a residential unit.

A Couple of Our Other Reads

You may be interested in reading our publishing about a Psychologist promoted to the level of Chief of Staff for the Harlingen area Veterans Affairs Health Care System.

Or you may find our publishing on a Texas Attorney General Annual Report for 2022.

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