New and recurring problems still plague VA seven years after scandal

VA inspector general issues 20 recommendations of improvement for one zone of facilities alone.

Updated: December 26, 2021 - 11:36pm

The Veterans Affairs’ Office of Inspector General released nine reports this month detailing deficiencies ranging from lung cancer screening to security requirements for veterans’ patient data.

The findings are a stark reminder that the federal agency that cares for millions of military veterans still suffers from problems seven years after an Obama-era scandal rocked Washington with revelations of long patient wait times and medical negligence.

Here are the latest warning signs and criticisms from the VA’s chief internal watchdog:

1. In a Dec. 16 report, the inspector general made five recommendations of improvement to the VA Southern Nevada Healthcare System in Las Vegas after it found that a patient's cancer wasn't treated after “providers failed to make a cancer diagnosis."

Following a 2017 chest CT scan where Radiology Service staff found that a renal nodule had increased in size, two primary care providers didn’t order screening tests that may have given them the information needed to make a diagnosis for a high-risk lung cancer patient.

The OIG made recommendations regarding the “evaluation of primary care and pulmonology processes for lung cancer screening and follow-up care; follow-up for abnormal radiology findings; surveillance for patients who have undergone prostatectomy; review of copy and paste practices and plan of care documentation in the electronic health record; and review of complaint reporting and responding.” 

2. In another Dec. 16 report, the VA inspector general found there was inadequate oversight of the Veterans Health Administration’s home oxygen program, which provides oxygen services through vendors to veterans in need of at-home respiratory care.

According to the report, home oxygen patients weren’t always reevaluated in a timely manner by prescribing providers, "and medical facility staff did not always conduct home visits for the required number of patients."

Differing interpretations of guidance and a lack of oversight caused inadequate monitoring by contracting officers and their representatives. At two facilities, the VHA paid for services with expired contracts. 

Six recommendations of improvement were made to the under secretary for health, including “implementing guidance for managing home oxygen consults, clarifying reevaluation timelines, updating responsibilities for home visit oversight, and requiring network contracting office oversight of contracting officers to ensure completion of evaluation and quality monitoring elements and to properly designate contracting officer’s representatives.” 

3. In 2016, the inspector general had released a report on the Veterans Benefits Administration’s monthly tax-free benefits compensation program for veterans who suffered from disabilities caused by disease or injury “incurred or aggravated during active military service.” 

The initial report had found that the VBA needed to improve its processing of special monthly compensation housebound benefits, as about 27% of the high-risk cases were incorrectly processed. 

Five years later, in a Dec. 15 report, the OIG found that the VBA had not improved the accuracy of its special monthly compensation housebound claims processing. 

4. On Dec. 15, a report was released by the inspector general on the improvements needed to ensure final disposition of unclaimed veterans’ remains

The VA is required to "ensure that deceased veterans without a next of kin receive dignified burials,” and that funeral homes are provided with information about the agency's burial benefits regarding “deceased veterans whose remains are unclaimed.” 

The inspector general found three areas where improvement is needed, including the “VA’s insufficient outreach” to entities likely in custody of unclaimed veterans’ remains; the VA’s financial oversight structure, which doesn’t allow for agency-wide or cross-administration accounting for payments made on behalf of deceased veterans' unclaimed remains; and the VA’s inadequate oversight at the department level of benefits and services for the unclaimed remains of deceased veterans. 

5. On Dec. 14, the OIG released a report on its comprehensive healthcare inspection of the Hampton VA Medical Center in Virginia

Six recommendations for improvement were issued by the inspector general regarding quality, safety, and value; registered nurse credentialing; mental health suicide prevention training; care coordination; and high-risk processes. 

6. The inspector general released a report on Dec. 9 regarding the West Palm Beach VA Medical Center in Florida, where two patients' organs were perforated during surgical procedures by a facility urologist.

The OIG found “deficiencies in the facility’s clinical and institutional disclosure processes ... quality processes involving patient safety reporting; the Surgical Workgroup’s oversight of Surgical Service Morbidity and Mortality Conferences; and peer review processes.” 

Seven recommendations of improvement were made by the inspector general regarding those deficient areas.

7. In a Dec. 7 report, the inspector general reviewed 36 VHA facilities during fiscal year 2020 for whether requirements were met for women’s health care, such as “processes related to the provision of care, program oversight and monitoring of performance improvement data, and assignment of required staff.” 

Across the facilities, weaknesses were found with 24-hour a day coverage of gynecologic care, designation of coordinators for maternity care, “assignment of at least two women’s health primary care providers for each community-based outpatient clinic, women veterans health committees’ inclusion of core members and reporting to clinical executive leaders, [and] assignment of full-time women veterans program managers who are free of collateral duties.” 

8. A Dec. 2 OIG report found that the VA’s Office of Information and Technology's Project Special Forces (PSF) division failed to meet security requirements for veterans’ patient data. 

PSF wasn’t fully following “VA policy for deploying software-as-a-service (SaaS) applications” or Federal Risk and Authorization Management Program (FedRAMP) policies, which provides a standardized approach to risk assessment and security for federal agencies and cloud technologies.

While the inspector general found that some issues have since been addressed, such as “updated security for external partner connections,” four recommendations were made to the acting chief information officer.

They included determining whether the use of unauthorized SaaS applications should be prevented and “whether the reviewed applications should be authorized or reported to the Federal Chief Information Officer”; "to implement alerts for interface-related abuse and to either use application programming interfaces that transmit sensitive information and requirements for cross-origin resource sharing or seek exceptions to the standards.” 

9. The inspector general released a Dec. 2 report on a region of vet centers, and specifically focused on four that were selected in Casper, Wyoming; Denver, Colorado; and El Paso and Midland in Texas.

The report included 20 recommendations for improvement with regard to leadership and organizational risks; quality reviews; COVID-19 response; suicide prevention; consultation, supervision, and training; and environment of care.