16-25-DI-14-3650-DI-13-4570 Agency Report

7/24/2019 16-25-DI-14-3650-DI-13-4570 Agency Report

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Honorable Carolyn N.Special

u.s.1

4-3650

July 8 5

r o < r " ' ' r ' r ~ ' r u ' lto your letter regarding allegations byZandt Veterans Affalrs 0/A) Medical Center, (hereafter,

Center) In Altoona, Pennsylvania. The whistleblowers alleged that an r o r > 1 ' I T ' I " \ r ' \ < O r

in Physical Medicine and Rehabilitation is neurologically impairedIncompetent to practice. Secretary me tothe enclosed report any actions in""'"' :lT.o.co Code 1213(d)

Secretary askedwhistle blowers' allegations to theled a on

to improve training andthe report, which I


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DEPARTMENT O f VETERANS AFfAIRSWashington, DC

Report to theOffice of Special Counsel

OS f i le Numbers 0114 3650 0113 4570

JamesE.

Van Zandt Veterans Affai rs Medical CenterAltoona, Pennsylvania

Report Date: May 11 2015

TRIM 2015 0..28


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Executive Summary

The Interim Under for Health 1/USH) requested that the Office of the MedicalInspector (OMI) assemble and lead a Department of Veterans Affairs (VA) team toinvestigate allegations lodged with the Office Special Counsel (OSC) concerning theJames E. VanZandt VA Medical Center (hereafter, the Medical Center), PhysicalMedicine Rehabilitation Service (PM RS), Altoona, Pennsylvania.

l 1 : l ln oC DeNofrio, PM RS Administrative Officer, Timothy Skarada, Physical andOccupational Therapy (P OT) Supervisor, both of whom consented to the rerease

names, that employees are engaging in conduct that may constituteviolations of laws, rules or regulations, and gross mismanagement. which may lead to asubstantial and specific danger to public health. The VA team conducted a site visit tothe Medical Center on February 9-11, 2015, and completed the second half of theinvestigation on February 17-18 2015.

Specific Allegations of Whistle blowers

1 PM RS chief, appears to be neurologically impaired andmpetent, yet continues to treat patients; and

2. Altoona VAMC officials have failed to respond to the continuing concerns regarding' impairment and incompetency.

VA substantiated allegations when the facts and findings supported that the allegedevents or actions took did not substantiate allegations when the facts andfindings showed the allegations were unfounded. VA was not to substantiateallegations when the available evidence was not sufficient support conclusions withreasonable certainty about whether the alleged event or action place.

After careful review of findings,recommendations.

Conclusions for Allegation 1

following conclusions and

VA did not substantiate neurologically impaired andincompetent He underwent neurological andneuropsychological in 2013, the results which indicated noevidence of impairment at that time. Some (but not all) witnesses described occasionalincidents of forgetfulness, slight confusion, or questionable judgment since then.

failed to communicate his findings and recommendations for treatment toprovider in at least three instances, while in other cases his documentationof consultation findings did not address the main reason for the consultation.underwent a general medicine and neurological evaluation i n - 2 0 1 5 the results ofwhich also indicated no evidence of impairment. Since his evaluations revealed noevidence of impairment, some of identified would be considered


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noncompliance with accepted physician practices and adherence to Medical Canterpolicies. and should e addressed as such.

ther Conclusions:

The Medical Centers first evaluation o f for impairment did not complywith the procedures outlined in VA a n ~Occupations Health Services

- was noncompliant with VHA Directive 2011-007. Required Hand~ u i r e m e n t s

Gloves were not readily available in the patient care area where Veteran 1 wasbeing treated.

It is not dear whether treatment of the patient on January 7 2014negatively impacted the I ' 'MIGI ' ' l t 'Q condition,

Veteran 3's death was not caused or hastened because he did not receive hismechanical lift

The Medical Center has a peer review process in place to review cases involvingPM RS aspects of care.

Recommendations to the Medical Center:

1. o n i t o r compliance with documentation requirements, and addressn o n o m ~additkmal training and administrative and disciplinary action asindicated.

2.

indicated.

compliance with maintaining patient privacy. Address anyappropriate disciplinary and administrative action as

3. Provide training to appropriate staff about VA Handbook 5019 and the process forevaluating a Title 38 employee for impairment.

4. Review all remaining consultations performed y from October 1 2013.to present. Evaluate w h e t h e r findingsadariss1he concems noted bythe referring provider, and w h ~ p o s etreatments are appropriate for thefindings. If not ensure patients receive an appropriate evaluation and treatment.

5. Provide additional training to about hand hygiene practices* asmandated in VHA Directive t assess for compliance and addressnoncompliance with appropriate actions as indicated.

6. Ensure that gloves are readily available In all clinical areas within the PM RS area.

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care

ordering MRis.determined that all

information provided

compliant with copy

When assigned as arequirements.

Currently a _rinformation forProfessional P.::.rth,l '' n:::.rve:.

2 b ~

pasting requirements noted in the local and

was compliant with

as

t the Medical Center

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ummary tatement

V has developed this report in consultation with other Veterans Health Administration(VHA) and VA offices to address OSC s concerns that the Medical Center may haveviolated law, rule or regulation, engaged in gross mismanagement and abuse ofauthority, or created a substantial and specific danger to public health and safety. nparticular, the Office of General Counsel (OGC) has provided a legal review, and theOffice of Accountability Review (OAR) has examined the issues from a HumanResources (HR) perspective to establish accountability, when appropriate, for improperpersonnel practices. VA found violations of VA and VHA policy.


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Table o ontents

Executive Summary ...................................................................................................... ii

I Introduction ............................................................................................................... 1

II Facility and VISN Profile .......................................................................................... 1

Ill. Specific Allegations o the Whistleblowers .............................................................. 1

IV. Conduct o Investigation .........................................................................................

V. Findings Conclusions and Recommendations ............ ............ ............ ............ ....... 3

Attachment A .............................................................................................................. 17

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I. Introduction

he 1/USH requested that OMIassemble and lead a VA team to investigate allegationslodged with OSC concerning the Medical Center's PM RS. The whistleblowers, both ofwhom consented to the release of their names. alleged that employees are engaging inconduct that may constitute violations of laws, rules or regulations, and grossmismanagement. which may lead to a substantial and specifiC danger to public health.The VA team conducted a site visit to the Medical Center on February 9-11, 2015, andconducted additional interviews by telephone onFebruary 17-18, 2015.

II Facility Profile

The Medical Center, part of Veterans Integrated Service Network (VISN)4, serves over87,000 Veterans in central Pennsylvania with a comprehensive range o generalmedical, specialty clinics. and long-term health care services. Of its authorized 68operating beds, 28 are assigned to acute care and 40 to long-term care. PM RS, alongwith P OT. provided 14,476 episodes of care during fiSCal year (FY)2013 and 13,746during FY 2014 to inpatients and outpatients. The Medical Center has a medicalresource-sharing agreement with the Department o Defense and graduate andundergraduate program affiliations with several universities and colleges.

Ill. Specific Allegations o the Whistleblowers

1 , PM RS chief, appears to be neurologically impaired andcontinues to treat patients; and

2. Altoona VAMCofficials have failed to respond to the continuing concerns regardingimpairment and incompetency.

IV Conduct o f Investigation

The VA team conducting the investigation consisted of InterimDirector, OMI; , Medical Investigator: ClinicalProgram Manager; HR Specialist. relevantpolicies, procedures, reports. memorandums. and otherdocuments listed in Attachment A. We toured the Medical Centers PM RS areal andheld entrance and exit briefings with VISN leadership.

VA Interviewedbothwhistleblowers via teleconference on February4, 2015, and inperson on February9, 2015. The team also interviewed the following MedicalCenteremployees:

Physiatrist, Chief. PM RSr-


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Quality Improvement Consultant/AccreditationOccupation Therapist

Physical TherapistRisk Manager

.....'UU' '' Worker

Physical TherapistI J M a f l l . A ' f l t a Supervisor

Credentialing Coordinator..n r.siCHI Therapy Assistant

Chief Primary Care Compliance OffiCer/ Executive Assistant for the Medical Center

Audiologist~ ~ j l f ~ tAdvocate

ProstheticsOccupational Health Physician

Acute and Long Term Care ServicePrivacy Officer

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Findings, Conclusions, and Recommendations

PM&RS. also as is a specialty with diagnosis,evaluation, and management of with painful or functionally limitingconditions that temporary or permanent impairment. 1 The ofphysiatry is to pain and enhance performance and quality life.Rehabilitation also known as are nerve,

I t : : ; > ; : : ~ ; : ; >that 2

Allegation 1: , PM&RS Chief. appears to be neurologicallyimpaired and incompetent* yet ,..,..,w1 U . S to treat patients.

orunablefrom one of

1 American of h v ~ i r n lMedicine and Rehabi ltation2 lbkt , ~ , = ~ ~ t J3 American Medica Assooia,tion Hfftli(}ffJI )(J lrr>nt>i"'"'rl l l '1 i l ' l ff l r '>Aft : l ,nt ()(Unethical v


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2013, Medical s n t forby a neurologist who not with the ~ i c i

evaluation revealed mild difficulty with but excellent judgment and Insight,medicine with attention to detail, normal diagnostic TD ' 'n

2 1 underwent further testing

whistleblowers allegations aboutoould be related to a neurological condition, referred

neurological and neuropsychological rather than for anas required in VA Handbook 5019.

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consultation, stated that he does not seem more forgetful than before and could cite noevidence that his ablfty to perform his job has been negatively impacted.

11 He also began forgetting administrative tasks such as how to use email.Several staff members also expressed concerns about i s

ability to perform his duties and treat and haver ~

DeNofrio and Mr Skarada that is forgetful, cannot performadministrative duties, and requests assistance or tasks he wasable to perform in the past. He becomes confused when faced withadministrative changes or instructions, nd appears to be uncertain aboutwhich employees he supervises.

Two staff members indicated that had sought their assistance withaccessing a computerized training staff members stated that accessingand navigating the module was more difficult than usual, and once they had helped himaccess the training, he was able to it without further assistance. Thecomputer specialist provided additional training and assistance withnavigating the computer system, that he needed no more assistance thanmany others. and she did not consider the amount o assistance he needed to be eitherexcessive or concerning. currant and previous secretaries stated theyhave never been asked to assistance with email. Some witnesses statedthat had asked for help accessing radiographic images; their impressionwas was not asking for their interpretation o the radiograph. but assistance withaccessing the electronic Image from the patient s medical record. Two therapistsassisted him with retrieving radiographic studies; one s t t e ~asked him hisinterpretation o the study and one stated had to bring thestudy up on the screen. All providers staff members indicated thatthey have never been asked to in the performance o his duties, norhad they observed other staff members with the treatment o his patients.

Ill. is Increasingly confused and agitated and Is prone to angryand erratic behavior.

Other than the whistleblowers, no staff members reported witnessing any angryoutbursts or erratic behavior displayed by

V ~ Mr DeNofrio and Mr Skarada also report thatabsent from their department during the day UU ITnn

According to staff members, Is usually present in the department, or easyto locate i not present. secretary stated that if he is not present in thedepartment, she is able phone and he responds to her calls andfollows up on any messages she leaves for him Currently, is assigned to16 different committees and regularly attends meetings . He isalso actively involved with many o the Medical Center s affairs activities andevents. No witnesses reported instances when was on duty and not

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available within a short period of time. Other than the whistleblowers. no staff membersrecalled any Instance when they witnessed leaving the Medical Centerprior to the end of his shift.

Some staff members noted that is frequently late for meetings and at times

appears unclear about the purpose meeting. However. they stated heparticipates appropriately. and white at times his verbal input is tangential, he is easilyredirected to the topie(s) at hand.

V. When is present, he has been observed treating patients hemeets room or without a consult referral orscheduled appointment makes clinical recommendations topatients in th physical therapy gym even though thepatients were not referred to him nor was h previously involved in theirtreatment.

Some physical and occupational therapists stated thatrecommendations to patients he observes while passing ym or the P OThallway. ased on his brief observation. he may recommend using an assistive device(e.g., walker. cane. 'flheelchair. etc.) that he beleves would the patienfsmobility. Some staff members expressed concern that is recommendingthese treatment modalities without assessing patients inquestion were not referred to for consultation, and are not patients he wascurrently treating. Other occupational therapy staff stated that they did notbelie was attempting to treat these patients himself. but ratherenco staff to arrange follow up with the patient's appropriate provider toobtain assistive devices needed to improve mobility. Witnesses noted this has alwaysbeen practice and is not a change in his approach.

The whistleblowers alleged that discusses confidential information, suchas th reason for the patienfs appo with patients in the hallways of the PM RSarea. No other staff members recalled witnessing such occurrences. toldV that these discussions occurred in nonprivate areas because the areanxious to discuss their concerns with him and frequently begin the conversation beforethey reached a private area where confidentiality can be maintained. On- 2015, the Chief of Staff counseled about this violation ofpatient privacy.

VI. repeatedly failed to communicate with primary care providerstre anrta tf eRiiPiS ts regarding his clinical treatment and

recommendations, or changes he m ~ to treatment plans.

All health care providers that we interviewed stated that responds toconsults In a timely manner, and communicates his find ngs recommendations tothem or in a face-to-face conversation. The Chief of Staff noted oneinstance In whiCh failed to complete documentation for a Community

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care

vn documentation of patient encounters is poor

The

a the wrong diagnosis or does not address thecondition for which the patient was referred to him.

e n ~ a t : e aIn questionableVA For example, ~ 0 1 4

hernia examination on an individual wasproper hygiene protocol, did not document the examination inrecords and later day did not the n r . . . . . .

and inappropriate + r e > ~ ~ ' ~ ~ ' ' t

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Veteran 1 is an 84-year-old male hospitaJized for an acute change in his mental status,who was admitted to the Medical Centers CLC for reconditioning In preparation fordischarge home. The patient was receiving P&OT while residing in the CLC. Accordingto both staff members present at the time o the incident, the Veteran was in PM&Rfortreatment and was very unsteady on his feet Both therapists were supporting him in

order to keep him in a standing position and prevent him from falling. One of theurercm sis suspected that the patient have had a hernia, and summonedto examine him. When arrived, he checked his pockets and

did not have any exa According to both staff members.there were no exam gloves in the area, nd proceeded to conduct theexamination without gloves. the examination withoutgloves because he was would not be able to keep the patientupright much longer. According to one of the therapists. did not wash hishands before or after examining the patient By not doing so, failed tocomply with standard precautions, as directed in VHADirective , RequiredHand Hygiene Practlc s, which states, AIIhealth care workers in direct patient contactareas, i.e., inpatient rooms. outpatient clinics, etc as well as those who may havedirect patient contact in other settings, such as radiology technicians, phlebotomists,etc are required to use an alcohol-based hand rub or antimicrobial soap and water toroutinely decontaminate their hands before and after having direct contact with apatient

Veteran 2 is a ss year-old male with a history o mid- and low back pain and PTSO. On- 2014, he presented to the Emergency Department (ED} for evaluation andtreatment of shortness of breath. A diagnosis of right-sided pneumonia was made andthe Veteran was given medication and diseharged. After diseharge from the ED hewent to PM&RS, asking for treatment of his rib pain. The PM&RS staff was unable toprovide any treatment at that time because of the patienfs continued discomfort anddifficulty breathing. n the patient was seen for follow up by his primarycare provider (PCP), who referred him to PM&RSfor therapy. After being evaluatedand treated b y he patient stated his nb pain wasAccording to a n q u r yconducted by the Medicalcontacted the patient's wife later that day to inquire about how the 1 \ ~ T i i . C . I \ TThe wife informed that the patient was In pain again, andoffered to give her performing an arm manipulation toThe wife stated she was not comfortable performing the maneuver. and declined, On- the patient began complaining of chest pain with a cough. He was re-~ n the EO and treated with medication. and discharged home. On

he was r&-evaluated In the ED for worsening pneumonia. He was admittedt n D i t ~ t l e l n tcare and transferred to the PittSburgh VA Health Care System VAHCS) for

thoracentesis and additional treatment. It is unclear whether treatment on- negatively impacted the patient's condition and to a o his

The whistJeblowers voiced a concern about the care provided byVeteran 2. Peer review is defined as an organized process ~ l ' l ' f Q I ' I

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inma1careo when unexpected or occurrences

may be to care provided. Per VHADirective 0-025, eview forQualityManagement It is VHApolicy that VISN and health care facility must

establish maintain a program of management purposesrelevant to care provided by the health care provider.areon llie

nn- \ JQ :U ' -""u , male with lung cancer in1 Veteran's condition continued to decline and caregiver

mechanical to assist with caring for the Veteran at home. On201 his PCP a for the Prior to

the living quarters to evaluated and thecaregiver trained how to use the lift Because the \ t & : ~ ; : : : ; r : : : nHome Based Primary Care (HBPC) program, HBPC u c l u o a u o ~ n a l

OI \JJr-tnnmthe

: l n r u c . c ~ . ethis consult fortime, the Medical has a r o c e ~ ; s

similar for non-HBPC patients who need a serviceteam. There Is no that the patient's death was

having the mechanical lift.

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general medicine physician oonduded t h a t did not appear to have any...........w ...a ..... cognitive defidts during the x a m ~ t hevaluators concluded that

did not have any significant cognitive defidts or neurological diseaseb a ~ e don examinations. Since his evaluations revealed no evidence ofimpairment, some of the issues identified would e considered noncompliance with

accepted physician practices and adherence to Medical Center policies, and should beaddressed as such.

Conclusions

V did not substantiate that is neurologically impaired andincompetent He underwent neurological andneuropsychological evaluations in 2013, the results of which indicated noevidence of impairment at that time. not all witnesses described occasionalincidents of forgetfulness, slight confusion, or questionable judgment since then.

failed to communicate his findings and recommendations for treatment totrAr,::.mr'ln provider in at least three instances, white in other cases his documentation

of consultation fmings did not address the main reason for the consultation. Heunderwent a general medicine and neurological evaluation i n 2015 the results ofwhich also indicated no evidence of impairment. Since his evaluations revealed noevidence of mpairment, some of the issues identified would be considerednoncompliance and should be addressed as such.

Other Conclusions

The Medical Center's first evaluation o for impairment did not complywith the procedures outlined in VA a n d ~Occupational ealth Services

w a s oncompliant with VHA Directive 2011-Q07 Required and~ u l r e m e n t s

Gloves were not readily available in the patient care area where Veteran 1 wasbeing treated.

i t is not clear whethernegatively impacted

treatment of the patient o 2014condition.

Veteran 3's death was not caused or hastened because he did not receive hismechanical lift

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Recommendations to the Medical Center;

1nonCOITU''Utll:lni' A

indicated.

2

indicated.

compliance withfor documentation requirements. and addressadditional training and administrative and disciplinary action as

compliance with maintaining patient privacy. Address anyappropriate disciplinary and administrative action as

3. Provide training to appropriate staff about VA Handbook 5019 and the procesS forevaluating a Title 38 employee for Impairment.

4 Review all remaining c o n s u l t ~byto present. Evaluate w h e t h e r ~ n d i n g s concerns noted bythe referring provider, and whether his proposed treatments are appropriate for thefindings. f not. ensure patients receive an appropriate evaluation and treatment.

5 Provide additional training to about hand hygiene practices. asmandated in VHA Directive ; assess for compliance and addressnoncompliance with appropriate actions as indicated.

6 Ensure that gloves are readily available in all clinical areas within the PM RS area.

7. Peer review the care provided to Veteran 2 b ~ .

Allegation 2: Altoona VAMCofficials have failed to respond to the continuingconcerns regarding impairment and competency. Specifically:

- did not meet the target performance goals of 90~ according to the appropriate standard.I.performance was measured at 73 rcent andstandard used to use order to avoid

a review of his pe Even under the altered standardcontinued to fail this performance measure in FY 2014.

One of the criteria the Medical Center assessed for OPPE in FYs 2013 and 2014 wasappropriateness of ordering of MRis. Evaluation of providers performance was basedon the McKesson lnterQual criteria which are used to determine whether a service isdinlcally indicated and provided at the appropriate level of care. When evaluated underthe lnterQual criteria - performance rate was 73 percent. less than thetargeted performance r c e n t

To more clearly evaluate the appropriateness of MRIorders. the Chief of Staffinstructed the Chief of Radiology to conduct a second level review oforders for MRis to determine appropriateness according to the The

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u d d i t i o n a l l y ~in the last quarter o 2 1 achieved an 87percent success rate on the measure or copying and pastingin records, where rate is 95 percent. In October 2 14t

achieved 4 percent in the area o inappropriate copyingperformance should have initiated a Focused

Professional uation FPPE), but no FPPE was initiated. Healso had a success rate o 73 percent or the measure o unsigned co-signatures greater than 7 hours, where the target rate is percent.


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known as then n n - r u - . O J " ' > . . I ' " I r i . O I ' U practitioners by a CQ-l :iJ(J

cosignature. co-signer a supervising practitioner who thefor the care of the patient. A co-signature responsibility for contents of the

noteand

concurrence with the note. If a cosigner, the requires signatureby the co-signer. In contrast, an designation is a communication toolto a to

During FY 2014 the percentage for co-signature that were completed within 72 hours. The target was 95 percent and

was 73 percent An was not initiated, the Qualityidentified as a co-signature within hours, and found

not as a and

IU. - Medical Center Director) approvedfor clinical privileges uly 2014, even thonumerous goals established in the OngoingEvaluation OPPE) criteria during FY 2013 and 2014

3

re-credentialingfailed to

ractice

2014


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1 VHA Handbool\.1100.19,11 Ibid,

2 Ibid.11 bid.


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approrecommendations or follow up information. July 201a of notes found that f f ' l r l t f : i i i ' \ .O.t ' l a detailed

. , , recommendations and t n t ' l i t ; < ; : ~ ' t i n r l ~the recommendations

had been acted upon in a timely manner.

Although not included in thea that aa gerontologist was

of concern that the gerontologistadditional duty o reviewing nonwVA care As such. It was the

gerontologist s responsibility review Mr. OeNofrio s medical to determinewhether Mr. OeNofrio should sooner and for a non-VA care

' ' ~ ' ' ' ' ' ' ' f < he seen at : : l n r \ t h ~ 1

Conclusions:

on information reprivileglng was

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o privacymedical record.

as a co-sig

Recommendationsto

the Medical

Summary Statement

6

the

as

DeNofrio s

a


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ttachment A

Documents Reviewed in Addition to the Electronic Medical Record:

American College of Radiology Order Appropriateness Criteria

Credentialing and Privileging folder for

Findings of VACO Privacy Office

McKesson lnterQual Criteria for MRIOrder Appropriateness

Medical Center Memorandum (MCM) OM-04 Computerized Patient/Resident RecordSystem CPRS). October 2013

MCM11-01. Medical Staff Executive Committee. October 2013

MCM11-09 Peer Review Processes. October 2013MCM 11-141 Health Status and lrr;psired Practitioner Program. October 2013

Medical Center s Medical Staff Bylaws, Rules and Regulations and Policies. 2013

Medical Staff Executive Committee Meetings Minutes

Neurological and Neuropsychological testing results

Occupational Health Record

Performance Appraisals

Reports of Contacting invoMng PM RS

Results of OPPE and FPPE reviews

VA Handbook 5019. Occupational Health Services October 15.2002.VHADirective 2010-025, Peer Review for Quality Management. June 3, 201 0

VHA Directive 2012.030 Credentlaling o Health Care Professionals. October 11. 2012

VHAHandbook 1100.19. Credentialing and Privileging. October 15 1 2012

VHAHandbook 1907.01 Health Information Management and Health RecordsJuly 22, 2014