HELENA — A report from a federal inspector says a former chief of staff at the Montana VA Health Care System violated policies for care, and that agency leaders had deficiencies in their oversight.
The U.S. Department of Veterans Affairs Office of Inspector General released its findings Tuesday in an investigation of Dr. JP Maganito, who resigned from the Montana VA in August 2022. He had been the chief of staff since 2019.
The report says Maganito practiced outside his approved clinical privileges, and that he provided substandard care to two female patients. It makes ten recommendations for local, regional and national VA leaders to address the deficiencies they identified.
According to the report, the Office of Inspector General received four complaints regarding Maganito between January and June of 2022. The report says the investigation began in June, and that inspectors spoke to many VA staff in virtual interviews and during a visit to the Fort Harrison facility in August 2022.
The report says investigators made multiple attempts to interview Maganito before and after his resignation, and that they eventually spoke to him in June 2023 – after issuing a subpoena and getting an order from a U.S. District Court judge directing him to testify.
Investigators say Maganito held clinical privileges for gynecology, but not for obstetrics or pregnancy care, and that he acted outside the scope of his privileges when he continued providing care to a patient in the second and third trimesters of her pregnancy. The report says the Montana VA Medical Center doesn’t approve providers to perform pregnancy care at that stage, because they don’t have the necessary infrastructure for care after the first trimester.
The report also says Maganito gave that patient substandard care when he evaluated her for two possible pregnancy complications instead of directing her to a community facility.
Additionally, investigators say Maganito failed to follow clinical standards with another patient, saying he ordered an inadequate antibiotic for her after a surgical complication, and that he should have ordered a biopsy to rule out cancer before doing a surgery on her.
The report said deficiencies in oversight meant quality-of-care concerns weren’t detected or addressed soon enough, which could have presented risks to patient safety. It recommended the Montana VA take six actions, including reviewing their policies on providers’ privileges and regular evaluations.
In a statement, Montana VA leaders said they “initiated aggressive actions to address the allegations against the former chief of staff” before the report was released. They said they’re working on action plans to address all the recommendations.
“Montana VA deeply regrets the circumstances that led to the investigation by the Office of Inspector General (OIG),” said Duane Gill, the Montana VA Health Care System’s interim executive director. “We take such incidents with utmost seriousness, as the well-being of our patients is our top priority.”