Supervision and Care of a Residential Treatment Program Patient at a Veterans Integrated Service Network 10 Medical Facility

The VA Office of Inspector General (OIG) conducted a healthcare inspection to evaluate the 2016 overdose death of a patient in a residential treatment program (Program) at a Veterans Integrated Service Network 10 medical facility (Facility). The purpose of the inspection was to review the supervision and care of the patient while enrolled in the Program. The OIG identified issues relating to the supervision of the Program patient. Supervision issues involved inconsistent Facility policy directions for patient check-ins, staff compliance with Veterans Health Administration (VHA) and Facility policies/procedures regarding the management of patient check-ins and missing patients when they failed to check-in, and random screening of patients for drugs and alcohol abuse. The OIG identified issues relating to the quality of care of the Program patient. Specifically, the OIG found that Program staff did not develop and implement a timely and comprehensive interdisciplinary treatment plan, provide services during the weekends, reassess the patient’s restrictions, and submit timely and accurate documentation as required by VHA and Facility policies/procedures. The OIG was unable to assess whether the impact of these failures directly affected the patient’s outcome. The OIG made five recommendations to the Facility Director related to the development and implementation of uniform Program policies and a comprehensive interdisciplinary plan, provision of daily services, the reassessment of patient privileges, and accurate electronic health record documentation. The name of the Facility is not being disclosed to protect the privacy rights of the subject of the report pursuant to 38 U.S.C. §7332, Confidentiality of Certain Medical Records, January 3, 2012.