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A veteran of the war in Afghanistan died of a heroin and cocaine overdose last year while receiving treatment at a Miami Veterans Affairs residential treatment facility, according to a VA inspector general report released Friday.
The veteran, who was in his 20s, had been diagnosed with post-traumatic stress disorder and other psychological conditions as well as traumatic brain injury. He had a history of drug abuse while in the Miami VA Medical Center substance abuse residential rehabilitation program and had previously lost leave privileges for continued use of alcohol and illicit drugs.
But according to the IG report, the medical facility staff failed to check him for contraband after he had been allowed to leave for an afternoon and also failed to monitor the facility closely, increasing the potential for visitors to bring in banned substances or for patients to leave to get them.
The investigation also showed that a third of the Miami program’s patients tested positive for drugs or alcohol during their stay.
“[These facilities] should provide a safe recovery environment for the treatment of patients with substance use disorders who require a controlled and sober environment. ... We found that the [Miami] unit did not consistently follow Veterans Health Administration policies that help establish a safe and secure environment,” the report noted.
According the the IG:
■The security surveillance camera for the program did not work at the time the patient died and still didn’t work three months later when the IG team visited.
■A staff member was not present at all times as required.
■Staff often stayed in a back room with limited view of the unit and no view of the entrances or exits.
Patients at VA residential rehab programs must be able to care for themselves and are allowed to leave the facilities with passes granted by the staff or their treatment providers.
This particular patient had previously been in a VA residential PTSD treatment program, where he failed four drug tests for amphetamines — although VA acknowledged the medications he was on may have contributed to those positive tests — and later tested positive for cocaine use.
The IG did not say the situation was reflective of a broader problem in VA residential rehabilitation programs. Instead, it gave recommendations for the Miami facility to solve its issues, including having adequate and trained staff and increasing its surveillance.
In her response, VA Sunshine Healthcare Network Director Joleen Clark concurred with the IG findings and said the facility is making the recommended changes.