OIG Monthly Highlights

Read about our top reports and investigations in December 2015 OIG REPORTS - Allegations of Lapses in Medical Record Documentation Substantiated at Perry Point, Maryland, VA Medical Center Residential Rehabilitation Program - The Office of Inspector General (OIG) conducted an inspection in response to complaints regarding documentation and follow-up of clinical events at the Mental Health (MH) Residential Rehabilitation Treatment Program (RRTP) located at Perry Point VA Medical Center (VAMC). The program is part of the Maryland VA Health Care System (HCS), headquartered in Baltimore, MD. OIG did not substantiate the allegation that facility staff did not follow sufficient practices to manage significant clinical events. OIG substantiated the allegation that some staff did not consistently document significant clinical events in patients’ electronic health records (EHR). OIG did not substantiate the allegation that subject policy-makers knew of documentation lapses but took no action to correct them. Prior to OIG’s inspection, and for unrelated reasons, the current MH Clinical Center Director identified concerns and took steps to revise and improve MH RRTP documentation processes. OIG found that the MH RRTP medical provider staffing of 1.2 providers was not compliant with the Veterans Health Administration’s required minimum core staffing guidelines of 2.3 providers and that staff did not consistently comply with all safe medication management documentation elements. On September 24, 2014, the Chief of Staff approved the hiring of one additional physician and two mid-level practitioners to cover MH rograms. OIG recommended that the System Director ensure that MH RRTP medical providers document information pertinent to medical decision-making related to clinical events in the EHR, managers review and address medical provider staffing needs, and staff document in the EHR all required elements of safe medication management for MH RRTP patients.