Pursuit's Take
OIG found that the Washington DC VA Medical Center has for many years suffered a series of systemic and programmatic failures that made it challenging for healthcare providers to consistently deliver timely and quality patient care. These breakdowns heightened the potential for fraud, waste, and abuse of government resources. Of the abuses, OIG found that the DC Medical Center lacked:
- The inability to consistently provide supplies, equipment, and instruments to patient care areas when needed;
- Ineffective sterile processing contributing to delays or postponements of procedures due to unavailable usable instruments;
- The lack of consistently clean storage areas for medical supplies and equipment;
- The failure to accurately and consistently track and trend patient safety events;
- Excessive vacancies in leadership positions and other pervasive staffing issues across multiple departments, including Logistics, Prosthetics, Sterile Processing, and Environmental Management Services;
- More than 10,000 open and pending prosthetic and sensory aid consults as of March 31, 2017, causing some patients to wait months for needed items;
- Financial and inventory systems producing inadequate data, lacking effective internal controls, and yielding no assurances that funds were appropriately expended;
- Approximately $92 million in supplies and equipment being charged to purchase cards over a two-year period without proper controls to ensure the purchases were necessary and cost-effective;
- Underutilization of the prime vendor contract that was designed to purchase supplies at more favorable prices;
- More than 500,000 noninventoried items maintained in an inadequately secured warehouse; and
- Patient protected health information (PHI) and personally identifiable information (PII) stored in unsecured areas.
Fortunately, these inefficiencies did not lead to patient deaths or other negative outcomes due to the commitment of healthcare professionals who worked around these challenges.
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