Recommendations
2194
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-03939-259 | Mental Health Inspection of the VA Kansas City Healthcare System in Missouri | Mental Health Inspection Program | ||
1 The Facility Director develops and implements clearly defined written processes for providing mental health care to veterans on medical units.
2 The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements.
3 The Chief of Staff ensures documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration and develops a plan to monitor for sustained compliance.
4 The Chief of Staff ensures veterans’ discharge instructions include the appointment location in easy-to-understand language.
5 The Chief of Staff ensures discharge instructions are free of medical abbreviations and includes the purpose for each listed medication and develops a plan to monitor for sustained compliance.
Closure Date:
6 The Chief of Staff directs staff to complete or review veterans’ suicide prevention safety plans prior to discharge from the acute inpatient mental health unit and develops a plan to monitor for sustained compliance.
7 The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including attendance at environment of care inspections, record of required members’ attendance at inspections in meeting minutes, and develops a plan to monitor for sustained compliance.
8 The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training.
Closure Date:
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| 25-03937-260 | Mental Health Inspection of the VA Jackson Healthcare System in Mississippi | Mental Health Inspection Program | ||
1 The Healthcare System Director ensures the Mental Health Executive Council includes ongoing veteran representation, in accordance with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA [Veterans Health Administration] Medical Points of Service.
2 The Associate Chief of Service, Mental Health ensures the local recovery coordinator serves in a full-time capacity, in accordance with Veterans Health Administration requirements Directive 1163, Psychosocial Rehabilitation and Recovery Services.
3 The Healthcare System Director ensures the physical environment on the inpatient mental health unit reflects recovery-oriented principles according to Veterans Affairs’ Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.
4 The Chief of Staff ensures compliance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures requirements related to documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration, and develops a plan to monitor for sustained compliance.
5 The Chief of Staff ensures veterans’ discharge instructions include the follow-up mental health appointment location information in easy-to-understand language, in accordance with Veterans Health Administration’s “Clinic Profile Management Business Rules,” and develops a plan to monitor for sustained compliance.
6 The Chief of Staff ensures discharge instructions include the purpose for each listed medication, consistent with Veterans Health Administration Directive 1345, Medication Reconciliation, and develops a plan to monitor for sustained compliance.
7 The Chief of Staff ensures staff provide a copy of the suicide prevention safety plan to veterans upon discharge from the inpatient unit, in accordance with Veterans Health Administration Office of Mental Health and Suicide Prevention Standard Operating Procedure 1160.06.2, “Standard Operating Procedure for Core Clinical Processes on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06,” and develops a plan to monitor for sustained compliance.
8 The Healthcare System Director instructs the Interdisciplinary Safety Inspection Team to record and report attendance of inspections to the Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, and develops a plan to monitor for sustained compliance.
9 The Healthcare System Director develops and implements a plan to monitor Mental Health Environment of Care Checklist training completion for sustained compliance, consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.
10 The Healthcare System Director ensures that Mental Health Environment of Care Checklist training completion attestation is accurately documented, in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.2, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Attestations Under VHA [Veterans Health Administration] Directive 1167,” and develops a plan to monitor for sustained compliance.
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| 25-03934-258 | Mental Health Inspection of the VA Boston Healthcare System in Brockton, MA | Mental Health Inspection Program | ||
1 The Healthcare System Director ensures the Mental Health Executive Council includes veteran representation, in accordance with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA [Veterans Health Administration] Medical Points of Service.
2 The Chief of Mental Health ensures staff develop and implement a local standard operating procedure for staff education and training on recovery-oriented care, consistent with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.
Closure Date:
3 The Chief of Mental Health ensures the local recovery coordinator conducts reviews of inpatient training material to maintain a recovery-oriented approach, in accordance with Veterans Health Administration Directive 1163, Psychosocial Rehabilitation and Recovery Services.
4 The Chief of Mental Health considers consultation with the Office of Mental Health to ensure facility policy aligns with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services, on veterans’ access to personal clothing on the inpatient units.
Closure Date:
5 The Chief of Mental Health ensures a minimum of four daily hours of recovery-oriented, interdisciplinary programming on the inpatient mental health units, consistent with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services, and develops a plan to monitor for sustained compliance.
6 The Healthcare System Director develops and implements written processes to ensure compliance with involuntary commitment requirements, in accordance with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.
7 The Chief of Staff ensures compliance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures, requirements related to documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration and develops a plan to monitor for sustained compliance.
8 The Chief of Staff ensures veterans’ discharge instructions include the appointment location in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”
9 In accordance with Veterans Health Administration Directive 1345, Medication Reconciliation, and Veterans Health Administration Health Information Management’s Health Record Documentation Program Guide Version 1.3, the Chief of Staff ensures discharge instructions include the purpose and dosing information for each listed medication in easy-to-understand language and develops a plan to monitor for sustained compliance.
10 The Chief of Staff directs staff to complete the Columbia-Suicide Severity Rating Scale within 24 hours before veterans’ discharge, consistent with Department of Veterans Affairs (VA) Suicide Risk Identification Strategy Minimum Requirements by Setting, and develops a plan to monitor for sustained compliance.
Closure Date:
11 The Chief of Staff directs staff to complete or review veterans’ suicide prevention safety plans prior to discharge from the inpatient mental health units, in accordance with Veterans Health Administration Office of Mental Health and Suicide Prevention Standard Operating Procedure 1160.06.2, “Standard Operating Procedure for Core Clinical Processes on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06,” and develops a plan to monitor for sustained compliance.
12 The Healthcare System Director directs staff to complete required suicide prevention training, according to the “Office of Suicide Prevention Suicide Prevention Mandatory Training Dashboard FAQ [Frequently Asked Questions],” and develops a plan to monitor for sustained compliance.
13 The Healthcare System Director instructs the Interdisciplinary Safety Inspection Team to adhere to Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, requirements related to attendance at inspections and record of attendance in meeting minutes, and develops a plan to monitor for sustained compliance.
Closure Date:
14 The Healthcare System Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards, in accordance with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.
Closure Date:
15 The Healthcare System Director directs inpatient staff and Interdisciplinary Safety Inspection Team members to complete Mental Health Environment of Care Checklist training requirements, consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, and develops a plan to monitor for sustained compliance.
Closure Date:
16 The Healthcare System Director ensures that Mental Health Environment of Care Checklist training completion is documented in attestations, in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.2, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Attestations Under VHA Directive 1167,” and develops a plan to monitor for sustained compliance.
Closure Date:
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| 26-02023-176 | Review of Supply Chain Management at the VA Augusta Health Care System in Georgia | Review | ||
1 Develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.
Closure Date:
2 Ensure all relevant supply chain staff receive appropriate and recurring training and require supervisors to perform ongoing monitoring—including periodic inventory reviews and root‑cause analyses—to strengthen controls over VA supplies.
Closure Date:
3 Develop and implement, in collaboration with the Veterans Integrated Service Network, local procedures that require custodial officers to notify supply chain staff when equipment is relocated, and establish protocols to validate and update equipment location and ensure equipment items are properly tagged.
Closure Date:
4 Ensure expendable supplies labeled expired are, in fact, expired and appropriate documentation is completed before turning the supplies in.
5 Address the physical security issues discussed in this report and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouses.
6 Evaluate contractor performance under the contracts awarded for inventory management systems in the Augusta VA Health Care System and take appropriate action to ensure performance in accordance with the contract and to recover funds.
7 Ensure supply chain management staff effectively address deficiencies identified during Veterans Integrated Service Network quality control reviews.
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| 23-03464-146 | Review of Contracted Backup Services for the Veterans Crisis Line | Review | ||
1 Confer with the VA Office of General Counsel to determine whether VA should assert a claim to recover the $11.2 million paid for services not received
2 Evaluate and take any needed actions to make sure policies and procedures require appropriate officials to accurately ascertain information security requirements for contracts that involve sensitive information prior to award.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $11,200,000
Closed: $0
Total: $11,200,000
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| 25-01011-154 | Review of VBA’s Processing of Adverse Actions for Service-Connected Disability Compensation | Review | ||
1 Create and mandate standardized due process letters for clear and unmistakable errors and severance of service connection, drafted in compliance with 38 C.F.R. § 3.103.
2 Update procedures to require an enhanced level of review for all final decisions associated with proposed adverse actions resulting from clear and unmistakable errors so that decisions are compliant with 38 C.F.R. § 3.105 and the M21-1 Adjudication Procedures Manual.
3 Develop an automated report that periodically identifies proposed adverse actions without a final decision and applicable pending end product, and ensure identified cases are reviewed and resolved as appropriate, to maintain compliance with the M21-1 Adjudication Procedures Manual and the M21-4 Manual.
4 Correct all errors identified by this review as appropriate, so claim processing actions are compliant with 38 C.F.R. § 3.103 and 3.105, the M21-1 Adjudication Procedures Manual, and the M21-4 Manual.
Total Monetary Impact of All Recommendations
Open: $16,895,038
Closed: $0
Total: $16,895,038
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| 25-03401-257 | Review of a Patient’s Care in the Intensive Care Unit at the Wm. Jennings Bryan Dorn VA Medical Center in Columbia, South Carolina | Hotline Healthcare Inspection | ||
1 The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that all patients admitted to the intensive care unit receive access to continuous critical care, particularly after hours, and clearly defines the role and responsibilities of the on-site intensivist and TeleCritical Care in the care of surgical intensive care unit admissions.
2 The Wm. Jennings Bryan Dorn VA Medical Center Director ensures that in the absence of patient-specific orders for vital sign parameters that warrant provider notification, intensive care unit nurses adhere to facility policy for provider notification parameters.
3 The Wm. Jennings Bryan Dorn VA Medical Center Director reviews VHA Directive 1155(1), Treatment of Acute Ischemic Stroke, August 22, 2025, and ensures the facility is in full compliance with current stroke center designation requirements, including protocols for inpatient stroke response, diagnostic imaging, consultation, and transfer processes.
Closure Date:
4 The Wm. Jennings Bryan Dorn VA Medical Center Director clarifies the qualifications for provider coverage in the intensive care unit and ensures all intensive care unit providers are appropriately privileged to deliver care in the intensive care unit prior to providing care.
5 The Wm. Jennings Bryan Dorn VA Medical Center Director determines whether providers delivered patient care in the intensive care unit without approved, current, facility‑specific privileges and, if so, completes required reviews and assessments in accordance with VHA requirements.
6 The Wm. Jennings Bryan Dorn VA Medical Center Director creates a process ensuring contract ICU physicians covering in the intensive care unit have access to the electronic health record for documentation and order writing from the start of their tour.
7 The Wm. Jennings Bryan Dorn VA Medical Center Director reviews this patient’s case and any associated quality management reviews, and if gaps are identified, develops an action plan to ensure quality management processes are completed in accordance with relevant VHA quality management directives.
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| 25-04252-256 | Healthcare Facility Inspection of the VA Mountain Home Healthcare System in Tennessee | Healthcare Facility Inspection | ||
1 Facility leaders take appropriate actions so staff develop a written workflow for each service that is consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
Closure Date:
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| 26-00032-248 | Healthcare Facility Inspection of the San Francisco VA Health Care System in California | Healthcare Facility Inspection | ||
1 The Director takes appropriate actions so fire doors close completely and latch, as required by National Fire Protection Association 80 Standard for Fire Doors and Other Opening Protectives.
Closure Date:
2 The Director takes appropriate actions so staff update the facility policy on test result communications to meet the requirements of Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
3 The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive take appropriate actions so staff develop, for each service, written workflows consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
4 The Director takes appropriate actions for the Chief of Staff to review Patient Centered Management Module data and address efficiency, capacity, and staffing needs, in accordance with Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.
Closure Date:
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| 26-00043-232 | Healthcare Facility Inspection of the VA New Mexico Healthcare System in Albuquerque | Healthcare Facility Inspection | ||
1 The Director develops workflows for all services that communicate test results to patients and includes the process for assigning designees (surrogates) for providers who order tests in the facility’s policy, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
Closure Date:
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15654