Healthcare Inspection – Lapses in Access and Quality of Care, VA Maryland Health Care System, Baltimore, Maryland

OIG conducted a review in response to concerns raised by Senator Barbara Mikulski regarding lapses in access and quality of care issues at the VA Maryland Health Care System. The purpose of this review was to determine the extent to which those concerns had merit. We substantiated delayed access for a patient at the Perry Point campus and identified some contributing factors, including insufficient primary care provider staffing. We substantiated that the system experienced challenges in providing timely access to orthopedic surgical services but had developed an action plan to address these issues prior to our visit. We did not substantiate concerns that a second patient experienced delays in service delivery or cancer diagnosis at the urgent care center at Perry Point. We also did not substantiate allegations related to a third patient’s diabetes and diabetic neuropathy pain; however, we found that community health care information was not included in the patient’s electronic health record because of provider documentation lapses and, possibly, a backlog of documents waiting to be scanned. We further found that the system’s policy for tube-feeding nutrition did not comply with all requirements. We made nine recommendations.