Review of VHA’s Oversight of Community Care Providers’ Opioid Prescribing at the Eastern Kansas Health Care System in Topeka and Leavenworth

Report Information

Issue Date
Report Number
22-02017-224
VISN
1
State
Kansas
District
Continental
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Major Management Challenges
Benefits for Veterans
Recommendations
13
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess care coordination for patients of the VA Eastern Kansas Health Care System (system) who received care and were dually prescribed opioids and benzodiazepines from Community Care Network (CCN) providers. The inspection also reviewed compliance with public law and Veterans Health Administration (VHA) policies and guidelines specific to the oversight of CCN provider opioid prescribing practices. The OIG found issues related to incomplete and delayed CCN provider documentation, Opioid Safety Initiative (OSI) prescribing risk mitigation strategies, prescriptions dispensed at VHA pharmacies versus non-VA pharmacies, and lack of medication reconciliation and VHA medication profile updates, which place patients at risk for adverse opioid related events. Additionally, the OIG identified two examples in which patients received multiple controlled substance prescriptions from a combination of system, non-system VHA providers, and CCN providers. The OIG found the Veterans Integrated Service Network (VISN) Director and system staff were not conducting oversight of CCN providers opioid prescribing practices as required under the MISSION Act and as recommended by the OIG in 2019 and were not reporting concerns of unsafe CCN provider practices to the third party administrator. The OIG made seven recommendations to the Under Secretary for Health related to CCN provider documentation, evidence of CCN provider training and use of OSI risk-mitigation strategies, state prescription drug monitoring program queries, and capture of CCN-prescribed medications in electronic health records (EHR). The OIG made two recommendations to the VISN Director related to ensuring the system has processes in place to conduct oversight of CCN providers’ prescribing practices. The OIG made four recommendations to the System Director related to documenting use of OSI risk-mitigation strategies, capturing CCN-prescribed medications in the EHR, filling vacant positions, and educating staff on reporting patient safety concerns involving CCN providers.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health collaborates with the region 2 third-party administrator to ensure that community care providers submit documentation of care to the Veterans Health Administration including treatments provided specific to opioid risk mitigation (urine drug screening, prescription drug monitoring program checks) and all prescriptions, to include urgently/emergently prescribed opioids and utine/maintenance opioid prescriptions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2024

The VA Eastern Kansas Health Care System Director ensures system providers document evidence of Opioid Safety Initiative risk-mitigation strategies for patients who are on long-term opioids, as required by Veterans Health Administration policy.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2025

The Under Secretary for Health develops and implements action requiring community care network providers to document evidence of application of Opioid Safety Initiative risk mitigation strategies when treating a veteran to whom they have rescribed opioids, and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health develops and implements action requiring community care network providers to conduct and document completion of state prescription drug monitoring program queries consistent with VHA policy, prior to prescribing controlled substances, regardless of whether the prescriptions are urgent, emergent, routine or maintenance prescriptions and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/11/2024

The Under Secretary for Health considers issuing formal guidance to all Veterans Health Administration pharmacy staff regarding best practices for conducting state prescription drug monitoring program queries upon receipt of controlled substance prescriptions from community care network providers.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2025

The Under Secretary for Health develops and implements a process to oversee compliance of VHA’s medication reconciliation process for patients receiving care in the community who are prescribed opioids to include recording of the prescriptions in the non-VA medication section of the medication profile.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2025

The Under Secretary for Health considers options and implements a process for including non VA medications prescribed by community care providers in the data populating the opioid safety tools.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2024

The VA Eastern Kansas Health Care System Director ensures that medications known to system staff are entered into the patient’s medication profile in the electronic health record.

No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2024

The VA Heartland Network Director ensures the Veterans Integrated Service Network Community Care Oversight Council conducts oversight of community care network providers’ opioid prescribing practices and reports results through the Opioid Prescribing Community Providers’ SharePoint site.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2024

The VA Heartland Network Director confirms that the VA Eastern Kansas Health Care System has a local process outlining expectations, roles, and responsibilities for completing reviews of community care network provider’s opioid prescribing practices and that the process is shared with system staff, initiated, and monitored.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2024

The VA Eastern Kansas Health Care System Director continues efforts to recruit and hire staff to fill vacant pain management positions.

No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2025

The Under Secretary for Health consults with the Office for Integrated Veteran Care to determine the value of including a review of community care network provider documentation for evidence of prescription drug monitoring program queries as a required element in VA’s Guidance for Community Provider Opioid Prescribing Practices Review.

No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2024

The VA Eastern Kansas Health Care System Director ensures system staff and leaders are educated on the processes to report patient safety concerns involving community care network providers.