All Reports

District leaders and the Phoenix and West Valley Vet Center Director collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Antelope Valley, Phoenix, and West Valley Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.

District leaders and the West Valley Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Antelope Valley, Phoenix, Santa Fe, and West Valley Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

District leaders and the Phoenix and Santa Fe Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

The New York/New Jersey VA Health Care Network Director conducts a review of system leaders’ responses to repeated concerns regarding delayed community care consult scheduling for patients with serious health conditions to determine whether leaders’ actions were in alignment with patient safety and high reliability organizational principles, and take action as warranted.

The New York/New Jersey VA Health Care Network Director ensures VA Western New York Health Care System Director develops community care consult practices and procedures for managing consults deemed high-risk or complex, implements an effective process to ensure consistency with processing consults within Veterans Health Administration timeliness requirements, and audits for compliance.

The VA Western New York Health Care System Director ensures system community care leaders develop and implement standardized operating procedures for consult management consistent with Veterans Health Administration standards, provide training to community care staff, monitor compliance, and evaluate effectiveness.

The VA Western New York Health Care System Director ensures all efforts to conduct an institutional disclosure to Patient A’s family are made and that the disclosure is documented in the patient’s electronic health record, as required.

The VA Tuscaloosa Healthcare System Director conducts a full review of care provided to the patient by clinical staff, consults with Human Resources and General Counsel Offices, and takes action as needed.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure that providers provide patient education about applicable boxed warnings when prescribing psychiatric medication, and monitors compliance.

The VA Tuscaloosa Healthcare System Director ensures mental health staff conduct suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates outpatient mental health clinic scheduling procedures; identifies barriers to timely appointment scheduling, including staffing levels; and takes action as warranted.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adequate lethal means assessment and lethal means safety counseling with patients.

The VA Tuscaloosa Healthcare System Director reviews posttraumatic stress disorder clinic processes to consult with a patient’s prescriber following worsening of a patient’s mental health symptoms.

The VA Tuscaloosa Healthcare System Director ensures posttraumatic stress disorder clinic consult and documentation procedures align with Veterans Health Administration requirements.

The VA Tuscaloosa Healthcare System Director conducts a review of the supervisory oversight of the social worker and other clinicians in the posttraumatic stress disorder clinic to ensure the identification and follow-up of clinical concerns for patients with complex mental health needs.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adherence to Veterans Health Administration and facility traumatic brain injury screening and consult requirements, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates the root cause analysis processes regarding reporting of incomplete action items in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates the Peer Review Committee processes on addressing identified system issues in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The Under Secretary for Health considers establishing written guidance regarding the Behavioral Health Autopsy Program family interview process, including suicide prevention program staff’s consultation, to ensure that the decision to not outreach a family member is based on the best interest of the family.

The VA Tuscaloosa Healthcare System Director ensures compliance with the Behavioral Health Autopsy Program including completion of the Family Interview Tool-Contact Form.

The VA Tuscaloosa Healthcare System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.

The VA Augusta Health Care System Director ensures that the Mental Health Executive Council includes veteran representation.

The Veterans Integrated Service Network Director implements processes to strengthen oversight and monitoring of bed utilization.

The VA Augusta Health Care System Associate Director for Patient Care Services ensures that inpatient mental health unit staffing supports authorized bed capacity.

The VA Augusta Health Care System Director develops and implements processes to incorporate veteran input for process improvements.

The VA Augusta Health Care System Chief of Mental Health develops processes to ensure integration of the Local Recovery Coordinator into the inpatient mental health unit to support recovery-oriented care.

The VA Augusta Health Care System Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures continued implementation of a recovery-oriented environment on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures accurate reporting of inpatient operating beds and implements processes to monitor.

The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.

The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.

The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans’ voluntary or involuntary legal status, consistent with VHA policy and state laws.

The VA Augusta Health Care System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for improvement.

The VA Augusta Health Care System Director ensures the development and implementation of clearly defined written processes for transition of care when veterans are discharged from the inpatient mental health unit.

The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.

The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.

The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.

The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.

The VA Augusta Health Care System Chief of Staff ensures that safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.

The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.

The VA Augusta Health Care System Director ensures compliance with VHA requirements for the Interdisciplinary Safety Inspection Team, including environment of care subcommittee structure, and Mental Health Environment of Care Checklist training completion.

The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.

Ensure the Network Contracting Office 12 contracting officer develops a cardiothoracic services contract solution that meets the Medical Sharing/Affiliate National Program Office threshold for review.

Establish procedures to regularly identify and review healthcare resources contracts that have been modified resulting in contract values that exceed the threshold and determine if any further action by Regional Procurement Office Central leaders or the head of contracting activity is necessary.

Ensure the Network Contracting Office 12 contracting officer makes the sole-source contract justifications publicly available as required.

Ensure corrective actions are taken to resolve the issues identified in the Medical Sharing/Affiliate National Program Office fact-finding investigation.

Establish and implement guidance for quality assurance measures over the data used to develop and justify the ambulatory care budget estimate.

Ensure the deputy under secretary for health provides oversight and holds the Office of Finance accountable for developing, documenting, and implementing standard operating procedures to include defining roles and responsibilities and requirements for oversight and quality assurance for development of the ambulatory care budget estimate.

Implement the Veterans Health Administration Data Governance Council, to include developing policies and processes for data management across the Veterans Health Administration.

Ensure the Veterans Health Administration Data Governance Council identifies authoritative data sources and nominates data stewards for approval by the VA Data Governance Council.

Coordinate with the Health Administration Service chief to develop local policy and standard operating procedures to ensure wheelchair-accessible transportation service invoices are adequately reviewed before certification for payment in accordance with financial policy and contract documentation.

Recover approximately $3.7 million from the contractor for transportation overcharges.

The OIG recommends that facility leaders submit a plan to the OIG detailing steps to address snow removal on pathways leading to and from buses during and after snowstorms.

The OIG recommends that facility leaders consider clarifying signage by identifying the services located in each building to help direct veterans.

The OIG recommends that facility leaders implement navigation tools and cues that accommodate visually impaired veterans to help them enter the main doors.

The OIG recommends that facility leaders consider distributing toxic exposure screening information where veterans can easily obtain it when entering the facility.

The OIG recommended the Facility Director work with Veterans Integrated Service Network leaders to reevaluate the current bed level capacity and submit the bed change request as required.

The OIG recommended the Facility Director ensures staff secure the pneumatic tube system to prevent unauthorized access to medications.

Assess electronic health record major performance incident data needs and contractually commit to real-time data sharing that will provide greater awareness of system operations.

Develop a formal procedure for verifying performance metrics and associated credits to ensure the department receives the remedies it is due under the contract.

Update the process for prioritizing major performance incidents to ensure that notification and resolution occur in a consistent manner.

Develop effective notification and resolution metrics that consistently capture results for all major performance incidents, regardless of the owner, and enforce them.

Identify the information needed in post-resolution reports, such as corrective and preventative actions, and require the contractor to consistently collect, verify, and report that information as a contract deliverable.

Develop a plan to ensure all clinicians are familiar with the national downtime procedures.

Identify the appropriate backup system and develop a training strategy to ensure clinicians can use the system during downtime.

Assess facilities’ patient safety reports identified during this audit to determine if additional actions need to be taken and, if so, provide an action plan.

Develop a mechanism to better identify major performance incidents and negative patient outcomes and provide a plan to prioritize and address their causes.

Establish a plan to use VA’s cost accounting system information to identify alternative ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy. This could include implementing federal financial accounting standard practices to use cost information for performance measurement, budgeting, cost control, and making economic choices.

Consider requiring that the managerial cost accounting team review the Intermediate Product Cost Outlier report to identify cost outliers that may occur at the healthcare system.

Ensure healthcare services are completing monthly data validation memos for their managerial cost accounting data.

Ensure that healthcare system staff follow policy requirements; and that fiscal staff conduct reviews on all open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations” (2020), updated May 2023.

Ensure that healthcare contracting staff follow federal acquisition regulations when terminating contracts for convenience to the government.

Establish controls to ensure cardholders comply with record retention requirements, confirm approving officials and cardholders review purchases for VA policy compliance, and ensure contracting is used when it is in the best interest of the government.

Require cardholders to submit a request for ratification for any unauthorized commitments identified.

Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package.

Develop and maintain a standardized training program for logistics and clinical staff on the proper recording of items as they are removed from primary and secondary inventory points.

Ensure that MSPV facility-level contracting officer’s representatives are appointed and designated properly and perform all required duties according to the scope and limitation of the designee’s authority.

Reevaluate the risk determination for the Veterans Health Administration Geographic Information System and determine if the system should be set to a security categorization level of “moderate” based on the personally identifiable information and other sensitive data maintained in the system.

Ensure the Data Breach Response Service director instructs staff associated with the incident response process that each security and privacy incident that occurs must be captured on a separate Privacy Security Events Tracking System ticket, confirms document investigation details are accurate, and reassesses whether the security incidents were a breach.

Request that the contractor perform a self-audit of local VA claims.

Verify that the contractor has completed the process of refunding local VA claims.

Establish policies and procedures for Grant and Per Diem liaisons to obtain reliable discharge information from grantees when veterans exit from the Grant and Per Diem Program.

Implement controls, including enhanced medical facility and grantee guidance and training, to ensure grantee files and VA medical record documentation of veteran housing outcomes are consistent with Homeless Operations, Management, and Evaluation System data definitions and support the data in the Homeless Operations, Management, and Evaluation System.

Implement controls, such as quality reviews, to ensure Homeless Operations, Management, and Evaluation System outcome data are supported by and consistent with veteran medical records and grantee files.

Confirm VA has resumed submitting biweekly reports and, therefore, has submitted reports from June 2023 to present as required by the VA Transparency & Trust Act of 2021.

Confirm that the American Rescue Plan Act of 2021 section 8002 quarterly reports are submitted to Congress within the time frame established on the Consolidated Appropriations Acts of 2022 and 2023, which is no later than 30 days after the end of each fiscal quarter.

Coordinate with administration and staff office chief financial officers to ensure that the finance office staff responsible for the management of open obligations know and understand VA financial policy requirements for the review of open obligations included in quarterly obligation reports.

Ensure that annual reports to Congress include the steps VA is taking to improve the onboard timeline for facilities for which the duration of the onboarding process exceeds the metrics laid out in the Veterans Health Administration’s time-to-hire model, or successor model, as required by section 3008(b) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.

Track facilities’ supply chain personnel vacancies as part of the quality control reviews and take appropriate action.

Develop guidelines that define when facility supply chain management problems require additional interventions and then routinely identify them for network director action.

Ensure facility and network directors work with the Procurement and Logistics Office on a plan to identify resources and milestones to resolve identified supply chain management problems for identified facilities.

Direct the program office to develop a process to provide resources when needed to help networks and facilities resolve persistent supply chain management deficiencies, including those identified in this report.

Continue Procurement and Logistics Office efforts to automate tracking that will accurately capture and monitor all quality control review results, corrective action plans, and implementation of those plans.

Update the Procurement and Logistics Office audits of the quality control program to apply risk‑based sampling, evaluate action plan sufficiency and implementation, and use the results to continuously improve quality control review guidance and requirements.