Review of Responsiveness to Patient Care Concerns, and Credentialing and Supervision of a Nurse Practitioner and Physician Assistant at the VA Loma Linda Healthcare System in California

The VA Office of Inspector General (OIG) conducted a healthcare inspection in response to an inquiry from Congressman Pete Aguilar and a complaint regarding patient care involving a nurse practitioner (NP) and physician assistant (PA) in the hematology/oncology section at the VA Loma Linda Healthcare System (system) in California. The OIG initiated the inspection in May 2025, conducted a site visit in June, and continued off-site inspection activities through November 2025.

The OIG determined that two of the NP’s patients, and two of the PA’s patients had hematology/oncology clinical care concerns. The Chief of Staff assessed the four patient cases through appropriate reviews; however, the Chief of Staff delayed the initiation of two peer reviews by approximately five months. Credentialing documentation confirmed that the NP and PA were credentialed and met Veterans Health Administration (VHA) requirements to provide hematology/oncology care at the facility. Service leaders supervised the NP and PA by completing focused and ongoing professional practice evaluations and appraisals, but delays occurred in completing the NP’s initial focused professional practice evaluation and a focused professional practice evaluation for additional privileges. Interviews revealed leaders’ lack of awareness of requirements and lack of a tracking system may have contributed to these delays. Ongoing professional practice evaluations were also historically late, though service leaders took corrective actions before the site visit. The OIG found the Chief of Staff had not designated collaborating physicians for the PA, which was corrected after OIG identified the issue.

The System Director concurred with the OIG’s two recommendations and shared plans and actions taken to address timely signing of designation memos for peer reviews and completion of focused professional practice evaluations. The OIG will continue to monitor VHA’s management changes to ensure effective programs for veterans.