Pharmacy Process Concerns and Improper Staff Communication at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations related to the prior authorization drug request process. The OIG substantiated that the prior authorization drug request consult template included limited space for prescribers to enter treatment rationale and prescribers did not always know about an option to document unlimited supplemental information. The Pharmacy and Therapeutics Committee included adequate mental health representation; however, the relationship between the committee’s leaders and the mental health representative was problematic and noncollaborative. While the OIG did not determine that the prior authorization drug request or appeals process delayed treatment, a mental health prescriber may have contributed to one patient not receiving medications. Prescribers were unfamiliar with, or erroneously understood, the process for expediting an appeal and mental health prescribers modified their prescribing practices to avoid pharmacy processes. Since 2019, facility leaders were aware of, and did not effectively resolve, unprofessional communications between Mental Health and Pharmacy Services staff, including a mental health prescriber improperly documenting critical comments and disagreeing opinions within patients’ electronic health records. Further, Pharmacy Services staff and leaders sent disrespectful emails about Mental Health Service staff. The OIG substantiated that a pharmacist canceled medication orders without communicating with a patient; however, facility policy requires the requesting prescriber, not the pharmacist, to notify the patient of medication information. The OIG did not substantiate that pharmacists canceled medication orders without communicating with the requesting prescriber or that pharmacist reviewers denied a large number of prior authorization drug requests. The OIG made five recommendations to the Facility Director related to prescriber education, promotion of mental health prescribers’ pursuit of the most effective treatment plan, review of improper electronic health record entries and email, and evaluation of ways to improve workplace relationships.