VA watchdog report recommends fixes for Atlanta VA Health Care System

The Department of Veterans Affairs Office of the Inspector General made 23 recommendations in a report issued about the Atlanta VA Healthcare System.

"The number of recommendations should not be used, however, as a gauge for the overall quality provided at this system," the report noted. "The intent is for system leaders to use these recommendations as a road map to help improve operations and clinical care. The recommendations address systems issues as well as other less-critical findings that, if left unattended, may eventually interfere with the delivery of quality health care."

Among the issues highlighted in the report was a failure to always perform urine drug tests connected with the provision of opioid medication.

"VA/DoD clinical practice guidelines recommend that providers conduct a 'UDT [urine drug test] prior to initiating or continuing LOT [long-term opioid therapy] and periodically thereafter,' the watchdog noted in the report. "The OIG determined that providers conducted initial urine drug screening in 81 percent of the patients reviewed. This resulted in providers’ inability to identify whether the remaining 19 percent of patients had substance use disorders, determine potential diversion, and to ensure patients adhered to the prescribed medication regimen."

Another area of concern was the mental health of veterans served by the Atlanta VA. "The healthcare system complied with requirements associated with tracking and follow-up of high-risk veterans," the report noted. 

But the suicide prevention coordinator (SPC) completed an insufficient quantity of outreach activities, according to the VA watchdog. 

"From October through December 2019, the OIG noted that the SPC completed 11 of the 15 required outreach activities," the report noted. "Failure to conduct outreach could negatively impact at-risk veterans who have not received mental health services at the VA."