Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection 

Review of Hospice Care Issues 

VA Maryland Health Care System 

Baltimore, Maryland 

Report No. 08-01634-38 December 8, 2008

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Call the OIG Hotline – (800) 488-8244 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

Executive Summary 

The VA Office of Inspector General, Office of Healthcare Inspections, reviewed 

allegations of inadequate pain management, poor hospice care, and ineffective 

communication at the VA Maryland Healthcare System (VAMHCS), Baltimore 

Rehabilitation & Extended Care Center (BRECC). The purpose of this review was to 

determine the validity of the allegations. 

The complainant, the patient’s wife, alleged that: 

• The patient did not receive adequate pain medication. 

• The clinicians did not provide the patient hospice care. 

• The patient’s physician did not communicate effectively with family members. 

We did not substantiate or refute the first allegation. We found that the patient’s 

physician did prescribe pain medications for the patient; however, we were unable to 

determine if the patient’s pain was appropriately managed because medical record (the 

record) documentation did not reflect pain assessments after each dose of pain 

medication. We recommended that pain assessments are documented in patients’ 

medical records according to the system’s policy. 

We substantiated the second allegation. We found that a majority of the staff who cared 

for the patient was not trained in end of life issues and the interim plan of care did not 

include hospice care. We recommended that BRECC staff caring for hospice patients 

receive the required training. 

We did not substantiate or refute the last allegation. We found that the patient’s 

physician and other clinicians documented education in the record with the family 

regarding hospice care; however, the family believed that the physician did not keep them 

adequately informed of the patient’s plan of care. We recommended that a dedicated 

interdisciplinary hospice team provide care for hospice patients. 

The Veterans Integrated Service Network 5 and VAMHCS Directors concurred with the 

findings and recommendations. They submitted acceptable action plans, which include 

policy review and education of staff, compliance monitoring of pain assessments, staff 

education on end of life hospice care, and a dedicated hospice interdisciplinary team 

providing care to hospice patients. We find the action plans acceptable and will follow 

up until the plans have been implemented. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General 

Washington, DC 20420 

TO: Director, Veterans Integrated Service Network 5 (10N5) 

SUBJECT: Healthcare Inspection – Review of Hospice Care Issues, VA Maryland 

Health Care System, Baltimore, Maryland 

Purpose 

The VA, Office of Inspector General (OIG), Office of Healthcare Inspections (OHI) 

conducted an inspection of the quality of care provided to a hospice patient at the VA 

Maryland Health Care System’s (the system) Baltimore Rehabilitation and Extended 

Care Center (BRECC). The complainant, the patient’s wife, alleged that the patient did 

not receive adequate pain medication, clinicians did not provide acceptable hospice care, 

and the patient’s physician did not communicate effectively with family members. The 

complainant sent a letter outlining these allegations to a Member of Congress, Veterans 

Integrated System Network (VISN) 5, system and BRECC staff, and the OIG Hotline. 

The purpose of this inspection was to determine the validity of these allegations. 

Background 

The system is comprised of the Baltimore VA Medical Center (VAMC), the Perry Point 

VAMC, the BRECC, and multiple community based outpatient clinics (CBOCs). The 

BRECC has 120 beds and provides geropsychiatry services, rehabilitation services, 

post-acute care, and hospice/palliative services for the system’s patients. 

Hospice is a mode of palliative care that generally signifies the presence of a terminal 

condition. Palliative care is a broad term that includes hospice care. The primary goal of 

palliative care treatment is comfort rather than cure in a person with an advanced 

disease.1

 

1

 VHA Directive 2003-008, Palliative Care Consult Teams (PCCT), February 4, 2003; VHA Directive 2002-038, 

Hospice and Palliative Care Workload Capture, July 5, 2002. 

VA Office of Inspector General 1 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

VA’s Office of Geriatrics and Extended Care (GEC) requires that “all medical centers 

assure that hospice care is made available to all enrolled veterans who need and select 

this type of care.”2

 GEC defines hospice and palliative care as: 

...a coordinated program of palliative and supportive services provided in 

both home and inpatient settings for persons in the last phases of incurable 

disease so that they may live as fully and as comfortably as possible. The 

program emphasizes the management of pain and other physical symptoms, 

the management of the psychosocial problems, and the spiritual comfort of 

the patient and the patient's family or significant other. Services are 

provided by a medically-directed interdisciplinary team of health care 

providers and volunteers. Bereavement care is available to the family 

following the death of the patient. Hospice services are available 24 hours 

a day, seven days a week. 

Hospice care generally requires the acknowledgment of the patient, the 

family, and the physician that the illness is terminal, that the primary focus 

of treatment is on comfort rather than cure, and that aggressive attempts at 

curative treatment are relinquished.3

Scope and Methodology 

On May 27, 2008, OHI inspectors interviewed the complainant to obtain additional 

information and clarify issues pertinent to her complaint. On May 28–29, OHI inspectors 

conducted an onsite inspection and interviewed system and BRECC senior managers, 

physicians, nurses, and other employees knowledgeable about the patient’s care. We 

reviewed the patient’s medical record, system policies and procedures, and other 

pertinent documents. We toured the BRECC campus, including the ward where the 

patient received his care. Our review focused on the care provided to the patient during 

his admission to the BRECC. We referred other issues brought to our attention during 

employee interviews to system managers for appropriate action. 

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.

Case Summary 

In 2003, the patient, a 59-year-old male, presented to a system CBOC complaining of 

persistent hoarseness. CBOC clinicians evaluated and treated the patient, but 

 

2

 VA Office of Geriatrics and Extended Care, “Hospice and Palliative Care,”

http://10.2.51.79/geriatricsshg/docs/HPcare.DOC , accessed on July 15, 2008; Veterans’ Health Care Eligibility 

Reform Act of 1996 (38 CFR §17.38). 

3

 VA Office of Geriatrics and Extended Care, “Hospice and Palliative Care.” 

VA Office of Inspector General 2 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

approximately 2 weeks later, he returned with complaints of continued hoarseness. He 

was referred to the ear, nose, and throat (ENT) clinic. ENT clinicians noted left vocal 

cord paralysis but saw no obvious tumor. Computed tomography (CT) scans showed a 

mass in the left lung suspicious for a neoplasm, and the patient was ultimately diagnosed 

with advanced lung cancer. 

Oncology clinicians managed the patient’s care from 2004 through 2007. The patient had 

chemotherapy and radiation treatment and CTs to monitor the progression of his disease. 

He was in remission from March 2005 until August 2006, when he presented to the 

system’s emergency department with confusion and speech problems. An imaging study 

showed changes in his brain that were indicative of metastatic cancer. The patient was 

given additional chemotherapy and radiation treatment. 

A March 2007 CT scan of the chest showed that the patient’s cancer had progressed, and 

treatment options (chemotherapy versus hospice care) were discussed with the patient 

and his wife. They decided to pursue more chemotherapy. A July chest CT scan showed 

continued progression of his disease, and hospice care was again discussed with the 

patient and his wife. At that time, they elected to try oral chemotherapy and more 

radiation treatments. 

In October 2007, a physician noted that the patient had decreased cognitive and physical 

functioning. That physician discussed palliative care with the patient’s wife, and she 

decided that she would care for the patient at home with the possibility of hospice care if 

his mental status did not improve. Later that month, the patient had a brief 

hospitalization at the Baltimore VAMC for ataxia4

 and multiple falls. At discharge, the 

physician recommended that the patient and his wife contact their oncologist to discuss 

further treatment options. 

Two days later, because the patient’s mental status was deteriorating and he was 

becoming increasingly difficult to manage at home, the oncologist referred him for 

inpatient hospice care. The patient was admitted the next day to the BRECC’s inpatient 

nursing home care unit for hospice care. However, the patient’s wife had concerns about 

his care and pain management and decided to take him home on day 3 of his admission. 

The patient received home hospice services and was subsequently admitted to a non-VA 

inpatient hospice unit where he died in late November 2007. 

 

4

 Ataxia: Incoordinaton. Stedman’s Medical Dictionary, 25th ed., 1990, p. 147. 

VA Office of Inspector General 3 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

Inspection Results 

Issue 1: Pain Management 

We did not substantiate or refute the allegation that the patient did not receive adequate 

pain management. We found that nursing staff documentation of pain monitoring did not 

meet the requirements of the system’s policy.5

 

The complainant told us that on the second day of the patient’s BRECC admission, a 

nurse told her that he was receiving 30 milligrams (mg) of morphine every 8 hours. 

Pharmacy records show that prior to the BRECC admission, the patient was receiving 

morphine 75 mg SR (sustained release) every 8 hours along with oxycodone—another 

narcotic medication—for breakthrough pain.6

 

The attending physician reviewed the patient’s medication orders at the time of his 

admission to the BRECC. The physician’s admission orders for pain medications 

included morphine 60 mg SR every 8 hours and acetaminophen 650 mg every 4 hours as 

needed. The physician told us that he spoke to the complainant and discussed the 

patient’s treatment regimen and medication changes at that time. The physician 

documented in the patient’s medical record that he explained to the patient, with his wife 

and son present, that “...we would adjust his medications based on our observations at 

BRECC.” In addition, he documented that the patient “...is on a number of medications 

that could contribute to his confusion and impulsiveness and we will assess to taper over 

the admission.” The physician told us that his rationale was to decrease medications to 

evaluate whether the changes would improve the patient’s mental status. On the day of 

discharge, the attending physician documented that the patient’s wife “...stated that he 

[the patient] was not getting as much pain medications here as at home...I [attending 

physician] explained that the nursing staff and I had not observed that he was having pain 

except when swallowing – that he was started on a treatment for possible candida 

esophagitis....” 

The system’s pain management policy states that patients are to be screened for pain on 

admission and discharge, when vital signs are taken, when there is a clinically significant 

change, before and after initiation of pain relief measures, and when transitioning from 

one type of pain control to another.7

 The patient’s pain level was documented as zero (no 

pain) on admission. However, his pain level was not assessed again for over 24 hours 

even though he received pain medications and had an additional vital sign check. 

Because the pain assessments were not done according to the system’s policy, we were 

unable to determine if the patient’s pain was appropriately managed. 

 

5

 VAMHCS (VA Maryland Health Care System) Policy Memorandum 512-127/NEU-004, Pain Management, 

October 2005. 

6

 Breakthrough pain: A transient increase in pain intensity from a baseline pain level. Dorland’s Illustrated Medical 

Dictionary, 30th ed., 2003, p. 1351. 7

 VAMHCS Policy Memorandum 512-127/NEU-004, p. 3. 

VA Office of Inspector General 4 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

A manager told us that because the patient’s admission pain assessment was zero, a pain 

management plan was not initiated. She told us that the computerized nursing assessment 

has now been modified to capture patients on scheduled narcotics who do not have 

complaints of pain at the time of admission but who obviously have pain control issues. 

Issue 2: Hospice Care 

We substantiated the allegation that the patient did not receive hospice care. 

The patient’s wife alleged that the patient did not receive adequate hospice care. In her 

letter she stated that “...during my time there no one came in to see him except to give 

him medicine and to take him to the dining room.” She was concerned that the patient 

would not receive proper care when the family was not present and that he would fall. 

Prior to October 2007, a palliative care physician was on staff, and specific beds on the 

first floor of the BRECC were designated as the hospice unit. However, a clinical 

manager told us that when the patient was admitted to the BRECC, a hospice program 

was not in place; rather, hospice services were being offered. The system did not have a 

palliative care physician on staff at that time,8

 and hospice patients were no longer 

assigned to designated hospice beds but were dispersed throughout the BRECC. 

The system’s policy9

 requires that all staff caring for hospice patients receive hospice 

training. We reviewed the training records of 21 BRECC staff who provided care for this 

patient and found that 16 had not received the required training. 

On the day of admission, the attending physician examined the patient, completed an 

admission note and an Advance Care Planning note,10 and requested that the patient be 

admitted to a nursing home bed with a hospice level of care. Initial patient assessments 

were completed by recreational therapy, social work, pastoral services, and nursing. 

However, the nursing interim plan of care11 did not address hospice care. 

Issue 3: Communication 

We did not substantiate or refute the allegation that there was poor communication by the 

attending physician. 

The complainant alleged that the attending physician did not appropriately communicate 

with her and her family. She said that when she tried to talk to the physician while he 

 

8

 According to system management, a physician was hired for the Hospice/Palliative Care Program, GLTC 

(Geriatric Long Term Care Clinical Center), in September 2008. 

9

 VAMHCS Policy Memorandum, 512-11/COS-013, End-of-Life/Palliative Care Policy, August 2007. 10 Advance Care Planning note: “This note includes discussions of the patient’s wishes regarding life-sustaining 

treatments, quality of life, hospice care and related comfort care issues.” VAMHCS Policy Memorandum 

512-11/COS-013. 

11 Interim plan of care: Registered nurses develop the interim plan of care within 24 hours of admission. VAMHCS 

SOP No. 102/GLTC-010, Developing a GLTC Interdisciplinary Treatment Plan, October 2005, p. 2. 

VA Office of Inspector General 5 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

was interviewing the patient, the physician told her not to talk, that there would be no 

other hospital visits for her husband, and that his condition was terminal. 

The attending physician documented that he had “...reviewed the advance directives, the 

terminal nature of his [the patient’s] condition, the goals of hospice care and the 

limitations of interventions that we would use in his care (including no transfer to 

hospital and no tubes), they [the wife and son] expressed understanding and agreement.” 

Documentation supports that other health care providers had also discussed hospice care 

with the patient’s family and that family members expressed an understanding of end-oflife care. 

Despite documentation of patient and family education in the patient’s medical record 

outlining the care that would be provided to the patient, the complainant told OHI 

inspectors that it seemed that “terminal care” was equivalent to “no care.” 

Conclusions 

We could not substantiate or refute that the patient’s pain was appropriately managed 

because pain assessment and relief measures were not documented according to the 

system’s policy. Because the patient was not in a designated hospice bed, the majority of 

staff members caring for him were not trained in hospice care, and his nursing interim 

plan of care did not address hospice issues, we concluded that the patient did not receive 

hospice care. While the patient’s medical record contains documentation that the 

physician communicated treatment and end-of-life care issues with the complainant, she 

believed that the physician did not keep her informed. 

Recommendations 

Recommendation 1. We recommend that the VISN Director ensure that the 

System Director ensure that pain assessments are documented in patients’ medical 

records according to the system’s policy. 

Recommendation 2. We recommend that the VISN Director ensure that the 

System Director ensure that BRECC staff caring for hospice patients receive the required 

training. 

Recommendation 3. We recommend that the VISN Director ensure that the 

System Director ensure that patients admitted for hospice care are provided that care by a 

dedicated trained interdisciplinary hospice team. 

VA Office of Inspector General 6 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

Comments 

The VISN and System Directors agreed with the findings and recommendations and 

provided acceptable plans to ensure that contract revisions are identified, addressed, and 

upheld. We find the action plans acceptable and will follow up until the plans have been 

implemented. 

 (original signed by:)

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General for 

Healthcare Inspections 

VA Office of Inspector General 7 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum

Date: October 3, 2008 

From: Director, Veterans Integrated Service Network 5 

Subject: Healthcare Inspection - Review of Hospice Care Issues, 

VA Maryland Health Care System, Baltimore, Maryland 

To: VA Office of Inspector General 

1. I have reviewed the comments provided by the 

Medical Center Director, VAMHCS and I concur with their 

response below. 

2. If further information is required, please contact 

Dennis Smith, Medical Center Director, VAMHCS, at (410) 

605-7016. 

 

 (original signed by:) 

SANFORD M. GARFUNKEL, FACHE 

VA Office of Inspector General 8 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

Appendix B 

System Director Comments 

Department of 

Veterans Affairs Memorandum

Date: October 3, 2008 

From: VA Maryland Health Care System Director 

Subject: Healthcare Inspection - Review of Hospice Care Issues, 

VA Maryland Health Care System, Baltimore, Maryland 

To: Network Director, VISN 5 (10N5) 

1. Attached please find the action plans for the three (3) 

recommendations from the Office of the Inspector General 

Healthcare Inspection Review conducted May 28-29, 2008. 

2. The professionalism and cooperative manner demonstrated 

by your team during this review process was appreciated by 

all. 

4. If you have any questions regarding this report, please 

contact Iris E. Pettigrew, Director Accreditation and 

Performance Improvement at 410-605-7009. 

(original signed by:) 

DENNIS H. SMITH 

VA Office of Inspector General 9 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

Director’s Comments 

to Office of Inspector General’s Report 

The following Director’s comments are submitted in response 

to the recommendation(s) in the Office of Inspector General’s 

Report: 

OIG Recommendation(s)

Recommendation 1. We recommend that the VISN 

Director ensure that the System Director ensure that pain 

assessments are documented in patients’ medical records 

according to the system’s policy. 

Concur Target Completion Date: Multiple 

The VAMHCS views this corrective action into several 

activities. 

1. The first is to provide additional understanding and 

clarification of the expectations for pain assessment 

documentation in the patients’ medical records as specified in 

the organization’s policy. There will be a review of the 

policies regarding pain assessment, care planning and 

documentation with all the Loch Raven VA Community 

Living Center (LR CLC), previously referred to as the 

BRECC, staff. In Nursing, staff identified as pain liaisons to 

the Nursing Inpatient Pain Committee will provide resources 

and ongoing information to the staff. Further, all new staff 

will receive this information during new employee 

orientation. The Director, Geriatrics Long Term Care 

Clinical Center (GLTC) and the GLTC Associate Chief 

Nurses and Nurse Managers are charged with assuring review 

of the policies with their staff. Target Completion Date: 

November 15, 2008 

2. Nursing is in the process of developing a Nursing 

Standard Operating Procedure to specifically outline expected 

documentation for GLTC Nursing in addition to the 

organizational policy. It will be published and reviewed with 

staff. Target Completion Date: January 5, 2009 

VA Office of Inspector General 10 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

3. Compliance will be determined using chart reviews. 

This review will include: the initial pain assessment on 

admission by nursing and providers, inclusion on the initial 

plan of care by providers and nursing staff, documentation of 

the effectiveness of chronic pain medication, if applicable, 

and the documentation of prn medication effectiveness, when 

applicable. The cohort sample will include all admissions for 

hospice service during October to December 2008 at the LR 

CLC and the Perry Point (PP) CLC up to a maximum of 30 

patients at each site. The findings will be tracked, analyzed 

and reported monthly by PI to the Director, GLTC, the GLTC 

Performance Improvement Sub-Council and reported bimonthly through the Executive Performance Improvement 

Committee (EPIC) to the Executive Committee of the 

Medical Staff and the Executive Committee of the Governing 

Body. A compliance rate of 90 percent is the target. Target 

Completion Date: February 28, 2009

Recommendation 2. We recommend that the VISN 

Director ensure that the System Director ensure that BRECC 

staff caring for hospice patients receive the required training. 

Concur Target Completion Date: February 28, 

2009 

Staff currently assigned to the LR CLC/Hospice area will 

receive a minimum of 5 initial hours of end of life or hospice 

care related training (including pain). The education will 

have specific venues targeted to all staff disciplines. After 

this initial training, a minimum of three hours education 

related to end of life or hospice care will be required. The 

hospice palliative medicine physician, who started 9/7/08, is a 

recognized end of life care education expert with over 25 

years of clinical practice and instruction and will be available 

for ongoing education for all staff. Compliance goal will be 

that 90 percent of staff will have the initial training in 4 

months. 

VA Office of Inspector General 11 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland 

Recommendation 3. We recommend that the VISN 

Director ensure that the System Director ensure that patients 

admitted for hospice care are provided that care by a 

dedicated trained interdisciplinary hospice team. 

Concur Target Completion Date: Multiple 

1. The VAMHCS is committed to providing veterans with 

excellent and compassionate hospice and palliative care, 

which includes end of life care. Presently, the LR CLC 

hospice interdisciplinary team (IDT) is comprised of a trained 

and dedicated physician with board certification in Hospice 

and Palliative Medicine having over 25 years of clinical and 

instructional experience, registered nurse, a social worker, a 

chaplain, pharmacist, and recreational therapist. The IDT 

will be fully functional within a month at both LR and PP 

CLC. Target Completion Date: November 1, 2008 

2. Compliance with the IDT rendering hospice and 

palliative care will be accomplished through chart review to 

determine attendance or review of identified issues based on 

the notation in CPRS as additional signer. Compliance will 

be that 90 percent of the team reviewed the note as indicated. 

Target Completion Date: February 28, 2009 

VA Office of Inspector General 12 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Annette Acosta, MN, FNP, RN, Team Leader 

781 687-2135 

Acknowledgments Kathy Gudgell, JD, BSN, RN 

Nelson Miranda, MSW 

VA Office of Inspector General 13 
Review of Hospice Care Issues, VA Maryland Health Care System, Baltimore, Maryland

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans Integrated Service Network 5(10N5) 

Director, VA Maryland Health Care System (512/00) 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senators: Barbara A. Mikulski, Benjamin L. Cardin 

U.S. Representatives: Elijah E. Cummings, John P. Sarbanes 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 14