Nine months after federal regulators revealed VA Loma Linda failed to oversee a company that encountered serious staffing shortages after assuming management of five outpatient clinics, the health care system has yet to implement recommendations for improvement, according to a top-ranking government official.
In oral and written testimony, David Case, acting inspector general for the Department of Veterans Affairs, told a House Veterans Affairs oversight subcommittee last week VA Loma Linda's failures in addressing known community care deficiencies is emblematic of a larger problem plaguing VA health care systems nationwide.
Deficiencies uncovered by federal inspectors often persist due to a lack of accountability by VA management, inadequate staffing and ineffective monitoring to detect and resolve issues, he said.
A 40-page OIG report released in April 2024 detailing VA Loma Linda's high usage of community care for new primary care illustrates failures by its leadership to tackle obvious flaws, according to Case.
Inspectors found VA Loma Linda, which serves more than 78,000 veterans, made 992 referrals in 2022 from its clinics in Rancho Cucamonga, Corona, Murrieta, Victorville and Palm Desert -- the highest among all VA community-based outpatient facilities, the report stated.
The clinics managed by Virginia-based STG International began operating the facilities on behalf of VA Loma Linda on Oct. 1, 2021.
About two weeks later, according to the OIG report, STGi operational problems surfaced when VA Loma Linda officials received a media inquiry about a patient who encountered "access issues" at the Palm Desert clinic.
VA Loma Linda officials expected the clinics would be fully operational, but found instead that services were limited to urgent or emergency care, the report states. By the end of 2021, each clinic provider was responsible for more than 1,400 patients, exceeding the maximum level established by the VA, the report states.
Six weeks after STGi assumed management, the five clinics had 63% of the staff required to operate the facilities. By February 2022, staffing levels at the clinics had increased to 73%, the OIG said.
As a result of staffing shortages and full caseloads for providers, VA Loma Linda officials in May 2022 paused enrollment for new patients at the five STGi-operated clinics and began referring patients to outside physicians in the community.
The OIG determined VA Loma Linda did not meet the VA's expectations for scheduling timely patient referral appointments.
After the pause in enrollment at the clinics, the average time frame for making appointments ranged from 28 to more than 53 days, far exceeding the VA's target of seven days, the OIG said.
Clinics operated by the Veterans Health Administration "were unable to absorb the additional patients, leading to an increase in the system's use of community care providers for primary care," Case said in the statement. "Further, the system's community care office was not able to timely process the consults and schedule community appointments."
Although the OIG did not identify any patients who experienced poor outcomes, the lack of formal oversight, a turnover in leadership positions and transition to a new contractor created a vulnerability in VA Loma Linda's clinic services, Case said.
The OIG made three improvement recommendations to VA Loma Linda Director Karandeep Sraon focusing on monitoring primary care staffing, the number of patients assigned to providers, timeliness of community care consultations and clinic oversight.
Sraon, medical center director at VA Loma Linda since 2019, has not implemented the recommendations, Case told the congressional subcommittee.
Sraon did not immediately respond to emails seeking comment on Case's testimony.
However, after the OIG report on community care was published last year, VA Loma Linda said it had taken steps to implement the recommendations. Clinical staffing was increased, sites were expanded and "multiple process changes" were swiftly enacted to improve care to veterans, VA Loma Linda said in a statement.
In a separate report released last month, the OIG detailed other administrative problems within VA Loma Linda's community care operations. Federal inspectors found that VA Loma Linda staff could not provide documentation that management reassessed staffing at required intervals.
The VA requires facility leaders to conduct an initial assessment using a community care operating model, then reassess staffing every 90 days.
"When facility leaders do not reassess staffing at the required intervals, they may fail to meet workload demands, whichcould negatively affect community care program operations and patient care," the OIG report states.
The VA also requires staff to import all community care documents in a patient's electronic health record within five business days of receipt. However, during the inspection, a VA Loma Linda community care manager described receiving 22 boxes of paper records found in the Health Information Services Department, the report said.
The manager said staff had sorted four of the boxes trying to determine whether community care or health information services should electronically scan the records, the oldest of which were dated February 2019. The manager also identified a scanning backlog of 3,357 community care medical documents that had been received by fax.
"Failing to promptly scan incoming medical documentation from community care providers could negatively affect care coordination and quality of care monitoring," the report said.
The OIG's community care findings are among a string of management issues that have plagued VA Loma Linda for nearly two years.
Embattled employees have complained of retaliation for reporting missteps, including the promotion of a supervisor who routinely harassed workers, the mismanagement of more than $1 million in patient transportation funds, and the illegal use of involuntary psychiatric holds.
In January, House Committee on Veterans' Affairs Chairman Mike Bost, R-Illinois, and Senate Committee on Veterans' Affairs Chairman Jerry Moran, R-Kansas, introduced legislation aimed at strengthening the VA's authority to hold poor-performing employees accountable.
The Restore Department of Veterans Affairs Accountability Act would give the VA authority to quickly and fairly discipline such employees by: