All Reports

Conduct national refresher training on the Electronic Health Record Modernization National Process Memorandum and assess training effectiveness

Consider updating VA Manual 21-4 to reflect that quality assurance measures include addressing failures to consider all Veterans Health Administration records as directed in the Adjudication Procedures Manual that are subject to an enterprise-wide search in the Compensation and Pension Records Interchange system whether or not directed to those records by the claimant and ensure staff are advised of the changes.

The Fayetteville VA Coastal Health Care System Director ensures time frames for interpretation of echocardiograms are formalized and monitors for compliance.

The Fayetteville VA Coastal Health Care System Director reviews Facility Policy 11-40, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge dated January 2022 and SOP 11-10, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge Standard Operating Procedure and confirms that policy and procedures for an admission requiring continuous renal replacement therapy align with equipment and trained staff available at the facility.

The Fayetteville VA Coastal Health Care System Director ensures facility staff are educated on the community living center delineation of after-hour coverage and monitors compliance.

The Fayetteville VA Coastal Health Care System Director confirms hospitalists are educated on reporting patient safety issues and monitors patient safety reporting compliance.

The VA Mid-Atlantic Health Care Network Director reviews privileging processes and policies to ensure that facility leaders follow privileging processes and monitors compliance.

The Fayetteville VA Coastal Health Care System Director requires the chief of medicine to use focused professional practice evaluations and ongoing professional practice evaluations to evaluate provider performance per policy and monitors compliance.

The VA Milwaukee Healthcare System director to establish a plan to use VA’s cost accounting system information for the development of relevant, detailed cost information and to identify alternative ways to reduce costs and enhance efficiency as identified by VA financial policy.

The VA Milwaukee Healthcare System director to consider a plan to align VA Milwaukee Healthcare System financial management practices with federal financial accounting standard practices. This could include using cost information for performance measurement, budgeting and cost control, and making economic choices.

The VA Milwaukee Healthcare System director to ensure initiating services communicate status of delivered orders in a timely manner so healthcare system finance staff can comply with VA Financial Policy, vol. 2, chap. 5, “Obligations Policy,” by ensuring monthly that proper accruals have occurred.

The VA Milwaukee Healthcare System director to collaborate with the Veterans Integrated Service Network chief financial officer and network contracting office to establish a monthly prioritized listing of contract modifications and canceled orders for goods or services that have not been addressed by contracting officers to ensure modification actions are completed.

The Veterans Integrated Service Network 12 director to work with the network contracting office to amend the current contract or establish a new contract to include all needed laboratory tests.

The VA Milwaukee Healthcare System director to establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.

The VA Milwaukee Healthcare System director to require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.

The VA Milwaukee Healthcare System director to develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package per Veterans Health Administration policy.

The VA Milwaukee Healthcare System director to develop better access controls over the contingency space, to ensure less accessibility to reduce missing inventory.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for Level 3 peer reviews.

The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Chief of Staff evaluates and determines reasons for noncompliance and ensures section or service chiefs define time frames for Focused Professional Practice Evaluations.

The Chief of Staff determines the reasons for noncompliance and ensures service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures Medical Executive Council meeting minutes consistently contain its recommendations for privileging requests

The Associate Director, Operations evaluates and determines any additional reasons for noncompliance and ensures staff inspect, test, and maintain all medical equipment.

The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain equipment and furnishings in good working order and keep areas used by patients clean, safe, and suitable for care.

The Director evaluates and determines reasons for noncompliance and ensures that only breathable shower curtains are present in mental health inpatient unit bathrooms.

The Chief of Staff or Associate Director, Patient Care Service/Nurse Executive determines the reasons for noncompliance and ensures video or audio monitoring equipment installed for patient safety purposes does not record and is only accessed and viewed by Veterans Affairs healthcare providers.

The OIG recommended the under secretary for benefits assess the loan comparison statement controls implemented in December 2021 and 2022 to ensure they operate as planned and confirm borrowers receive these statements as required.

The OIG recommended the under secretary for benefits seek a legal opinion from the VA’s Office of General Counsel on the allowability of fees initially charged as itemized fees to be retroactively accepted as part of the 1 percent flat charge if unsupported, and then review the potential overcharges identified in the audit sample to determine if action is needed to make the borrowers whole.

The OIG recommended the under secretary for benefits develop and update policies and procedures to ensure invoices or bills are obtained for all third-party charges and lenders report itemized closing costs at the lowest level of detail.

The OIG recommended the under secretary for benefits develop and update policies and procedures for the state deviation process and requirements, assess the extent of missing VA authorizations on the schedule of state deviations and obtain the necessary documentation, and obtain a legal opinion from the VA’s Office of General Counsel on the allowability of state deviation charges in excess of the state-published amounts, and then review the potential overcharges identified in the audit sample to determine if action is needed to make the borrowers whole.

The OIG recommended the under secretary for benefits revise policies and procedures to comply with federal regulations on the itemization of costs charged under the 1 percent flat charge to ensure closing costs are properly charged.

The OIG recommended the under secretary for benefits obtain a legal opinion from the VA’s Office of General Counsel on the allowability of mortgage brokerage fees charged under the 1 percent flat charge, and then review the potential overcharge identified in the audit sample to determine if action is needed to make the borrower whole.

The OIG recommended the under secretary for benefits provide lenders at least annual communication about the importance of providing justifications for any loans not reported within 60 days.

The OIG recommended the under secretary for benefits modify policies and procedures for full-file loan reviews to include detailed steps for loan specialists to conduct reviews, as well as the risk factors and methodology for loan selection.

The OIG recommended the under secretary for benefits update policies and procedures to ensure the borrower is reimbursed for any overcharges identified during regional loan center quality reviews.

The Richard L Roudebush VA Medical Center Director ensures the Chief of Staff, chief of medicine, and chief of cardiology, in consultation with the National Cardiology Program Office, reevaluate the Cardiology Department and establish and implement a long-term service plan that includes cardiology services and cardiologist and specialty cardiologist staffing levels.

The Richard L Roudebush VA Medical Center Director provides the chief of cardiology with the dedicated resources needed to develop, implement, and sustain Cardiology Department changes.

The Veterans Integrated Service Network Director provides oversight of the Richard L Roudebush VA Medical Center Director’s development and implementation of a long-term Cardiology Department plan, monitors the department’s progress, and ensures changes are sustained.

The Veterans Integrated Service Network Director ensures the Richard L Roudebush VA Medical Center Director continues to strengthen and maintain the Cardiology Department’s relationship with the university affiliate, including residency and fellow cardiology programs and joint efforts to recruit cardiologists.

The Pension and Fiduciary Service clarifies procedural requirements to fiduciary hub staff on how to verify whether VA-derived funds of deceased beneficiaries must be returned to VA, including whether the fiduciary identified any valid will or heir to whom the funds are otherwise due.

The Pension and Fiduciary Service identifies existing or implements new electronic controls that allow VBA staff to track Fiduciary Program tasks, timeliness, and workload related to the return of deceased beneficiaries’ VA-derived funds to VA that would otherwise escheat to a state if not disbursed to heirs.

The Pension and Fiduciary Service and the Office of Field Operations establish a methodology and monitor workload to ensure the prompt return of deceased beneficiaries’ VA-derived funds.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by allowing a facility to conduct lung cancer screening while developing all mandated elements.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements.

The Under Secretary for Health considers mandating eligible patients be offered lung cancer screening consistent with other required cancer screening in the Veterans Health Administration.

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.

The Charlie Norwood VA Medical Center Director establishes a process to optimize communication between the Surgery Service and the Spinal Cord Injury Service when providing care to spinal cord injury patients.

The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

The System Director determines any additional reasons for noncompliance and ensures staff conduct required preventive maintenance on medical equipment.

The Chief of Staff determines the reasons for noncompliance and ensures only authorized staff have access to medications.

The System Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.

The Charles George VA Medical Center Director evaluates processes for mental health consult scheduling, including community care referrals, and ensures patients are offered timely appointments, per Veterans Health Administration policies.

The Charles George VA Medical Center Director confirms outpatient Mental Health staff receive education about Veterans Health Administration and facility policies related to mental health consult processes, including timeliness and community care consults.

The Charles George VA Medical Center Director evaluates the design, staffing, and implementation of the Behavioral Health Interdisciplinary Program to ensure the program supports timely access to mental health care and takes action as appropriate.

The Charles George VA Medical Center Director confers with Mental Health leaders to identify, track, and mitigate barriers to staff retention and takes appropriate action.

The Charles George VA Medical Center Director ensures Mental Health leaders review current communication practices within Mental Health operations, in accordance with Veterans Health Administration High Reliability Organization values and principles and considers the use of VHA resources, such as the National Center for Organization Development.

The Charles George VA Medical Center Director ensures Mental Health leaders educate Mental Health clinic staff on the role of the suicide prevention team in patient care.

The Charles George VA Medical Center Director reviews and evaluates processes for monitoring and managing Veterans Health Administration-required follow-up care for patients with high risk for suicide patient record flags, including scheduling and tracking of required follow-up appointments, and monitoring compliance.

The Health Care System Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews, and supervisors ensure implementation of those actions.

The Health Care System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews Ongoing Professional Practice Evaluation results and documents privileging decisions in the meeting minutes.

The Associate Director for Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures staff check supply rooms for expired supplies and discard them.

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders evaluate sentinel events and conduct institutional disclosures when criteria are met.

The Director determines any additional reasons for noncompliance and ensures the Comprehensive Environment of Care Coordinator or designee schedules and ensures staff complete environment of care inspections in patient care areas at the required frequency and document the inspection results.

The Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and furnishings and equipment safe and in good repair.

The Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.