All Reports

The Director takes appropriate action for employees to keep patient care areas clean as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program and clean storerooms as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action for employees to inspect and test all medical equipment as required by The Joint Commission standard PE [Physical Environment] 04.01.01.

The Director takes appropriate action so pharmaceutical waste containers are provided and accessible, and trains employees on container use as required by Veterans Health Administration Directive 1850.06(1), Waste Management Program.

The Director takes appropriate action so employees secure power strips as required by National Fire Protection Association’s Health Care Facilities Code, NFPA 99 and electrical cords are connected to prevent pulling or straining as required by National Electrical Code, NFPA 70.

The Chief of Staff and Associate Director for Patient and Nursing Services develop service-level workflows that outline responsibilities in the patient notification process and update the facility’s test result communication policy to align with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Chief of Staff and Associate Director for Patient and Nursing Services implement actions based on external peer review data to improve providers’ communication of test results to patients, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director performs a comprehensive safety risk assessment of enclosed walkways and implements necessary corrective actions to mitigate slip hazards, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions for staff to regularly identify and remove expired supplies in all areas outside standard supply rooms to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Veterans Integrated Service Network Director monitors the facility’s processes to prevent repeat environment of care findings and takes any needed actions to meet the requirements of Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate action so staff conduct a risk assessment to identify areas that need temperature and humidity monitoring and implement changes accordingly to comply with Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate action so staff secure liquid nitrogen tanks, maintain unobstructed access to exits, conduct a risk assessment on safe liquid nitrogen storage options to increase safety, and implement changes accordingly to align with the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code NFPA 55, Health Care Facilities Code NFPA 99, and Code of Federal Regulations title 29, section 1926.34.

The Director takes appropriate action so staff improve processes to prevent repeat environment of care findings as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director develops and implements a plan to repair and maintain facility walls, floors, and ceilings, and keep clean and dirty items separate, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director implements measures to monitor medication room temperature and humidity in the intensive care unit and community living center, in accordance with Veterans Health Administration Directive 1108.07(2), General Pharmacy Service Requirements.

The Director takes appropriate actions to strengthen staff accountability for maintaining clean and safe patient care areas as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions so staff validate and document airflow testing in supply rooms annually as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.

The Director takes appropriate actions so staff conduct a risk assessment to identify areas that require temperature and humidity monitoring and implement changes as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations and Veterans Health Administration Directive 1108.07(2), General Pharmacy Service Requirements.

The Director implements controls so staff repair or replace malfunctioning fire doors to ensure proper closure during emergencies as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

The Director implements measures so staff conduct all required fire safety inspections and document the results as required by the National Fire Protection Association’s Standard for Fire Doors and Other Opening Protectives, NFPA 80.

The Director takes appropriate actions to implement measures to test sprinkler systems as required by the National Fire Protection Association’s Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, NFPA 25.

The Director takes appropriate actions so staff evaluate processes to prevent repeat environment of care findings and take actions as warranted.

The Veterans Integrated Service Network Director monitors for similar or repeat environment of care findings and takes appropriate actions so facility leaders develop and implement facility-wide corrective action plans and sustain improvements.

The Director takes appropriate actions so each service chief develops a workflow that describes staff members’ roles in the process of communicating test results to providers and patients as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Director takes appropriate actions so staff track root cause analysis–driven improvement actions through to completion, monitor outcome measures, and implement processes to sustain improvements to comply with Veterans Health Administration National Center for Patient Safety’s Guide to Performing Root Cause Analysis.

The Chief of Staff takes appropriate action for evaluation and improvement of processes to identify adverse events that warrant institutional disclosures to patients or their representatives as required by Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients.

The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.

The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.

Develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

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.

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.

Ensure expendable supplies labeled expired are, in fact, expired and appropriate documentation is completed before turning the supplies in.

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.

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.

Ensure supply chain management staff effectively address deficiencies identified during Veterans Integrated Service Network quality control reviews.

The Associate Director keeps patient care areas clean and stores dirty and clean items separately.

Develop and establish guidance detailing how medical facility staff must document evidence to support their decisions when they make pharmaceutical purchases through the open market.

Ensure medical facility leaders conduct routine assessments of pharmaceutical purchases made through the open market so purchases are made in accordance with policy.

Develop a mechanism, in coordination with VHA’s purchase card program office and VA’s Office of General Counsel, that provides visibility into all pharmaceutical purchases, including purchases outside the prime vendor contract.

Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff periodically review unit conversion factors in the Generic Inventory Package to ensure accurate system values and quantities are recorded and then correct any discrepancies.

Require medical facility directors in Veterans Integrated Service Network 8 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.

Ensure medical facility directors in Veterans Integrated Service Network 8 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.

Ensure medical facility directors in Veterans Integrated Service Network 8 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated and establish protocols to validate and update equipment location during clinical moves or room changes and ensure equipment items are properly tagged.

Require medical facility directors in Veterans Integrated Service Network 8 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.

Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated Service Network’s quality control reviews.

Require medical facility directors in Veterans Integrated Service Network 22 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Require medical facility directors in Veterans Integrated Service Network 22 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.

Ensure medical facility directors in Veterans Integrated Service Network 22 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.

Ensure medical facility directors in Veterans Integrated Service Network 22 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated, establish protocols to validate and update the equipment location, and ensure equipment items are properly tagged.

Require medical facility directors in Veterans Integrated Service Network 22 to ensure facilities conduct annual inventory of nonexpendable equipment.

Require medical facility directors in Veterans Integrated Service Network 22 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.

Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated System Network’s quality control reviews.

The Michael E. DeBakey VA Medical Center Director uses available resources to help recruit and hire an assistant chief of Sterile Processing Services.

The Michael E. DeBakey VA Medical Center Director, in conjunction with the chief of Sterile Processing Services, reviews reusable medical device inventory management and oversight processes to ensure compliance with Veterans Health Administration requirements, identifies deficiencies, and takes action as warranted.

The Michael E. DeBakey VA Medical Center Director reviews processes to track issue briefs related to surgery cancellations resulting from reusable medical device issues from initiation to closure, identifies deficiencies, and takes action as necessary.

The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.

The Executive Medical Center Director ensures staff store clean and dirty equipment and supplies separately.

The Executive Medical Center Director ensures each service has workflows to communicate test results.

Executive leaders ensure staff properly store endoscopes.

The Medical Center Director ensures each service develops a workflow for the communication of test results.

The Medical Center Director ensures quality management staff report deficiencies identified from the External Peer Review Program to executive leaders, and staff take corrective actions as needed.

Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.

Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.

Facility leaders ensure staff label opened multidose medications with expiration dates.

Facility leaders ensure staff store clean and dirty items separately.

The Director ensures staff implement processes to prevent repeat environment of care findings.

The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.

Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.

Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.

Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.

Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.

The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.

The Executive Director ensures signs are present and accurate throughout the facility.

The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.

The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.

The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.

The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.

The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.

The Medical Center Director ensures staff properly store clean medical equipment.

Facility leaders develop written workflows for each service to ensure timely communication of test results to providers and patients.

The Director ensures staff keep the environment clean and safe.

The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.

The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.

Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.