Healthcare Inspection Alleged Pain Management Deficiencies, VA Maryland Health Care System, Baltimore, Maryland

OIG conducted a review to determine the validity of two allegations regarding hospice care at the Baltimore VA Rehabilitation and Extended Care Center, which is part of the VA Maryland Health Care System. OIG substantiated that two patients did not have adequate pain management as defined by Veterans Health Administration policy and hospice industry standards. The review identified five factors that contributed to the pain management deficiencies: (1) facility staff did not develop individualized and comprehensive pain management care plans, (2) patient pain reassessments were not appropriately documented, (3) clinical staff did not have sufficient training on the principles of pain management for hospice patients, (4) hospice interdisciplinary teams were not effectively used, and (5) clinical pharmacists were not actively involved in the pain management process. OIG did not substantiate that the lack of “piped in” oxygen, suction, and air compromised hospice patient safety and comfort. OIG found that the facility provided appropriate oxygen, suction, and air. OIG made four recommendations to address the factors that contributed to the pain management deficiencies. Management agreed with the findings and recommendations and provided acceptable improvement plans.