All Reports

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure providers counsel patients who have the potential to become pregnant on the risks and benefits of teratogenic medications prior to prescribing them and document this counseling in the electronic health record.

Establish robust oversight of the personnel suitability program within responsible office(s) that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Reimplement the monitoring program specifically required by VA Handbook 0710 as part of VA’s oversight efforts, or an appropriate equivalent, to identify and prevent systemic weaknesses in the personnel suitability program.

Assess program resources and allocate staff as needed to prioritize oversight of the personnel suitability program within responsible office(s).

Establish a plan to implement the updated staffing metrics for the Veterans Health Administration’s suitability function and consider using available hiring flexibilities.

Incorporate formal data-testing procedures (and data-matching as appropriate) of HR Smart and the VA Centralized Adjudication Background Investigation System (or any replacement systems) into the monitoring program discussed in recommendation 2.

Develop and execute a plan to collect, maintain, and access sufficient and appropriate data through a single system to support the tracking of background investigations from initiation to adjudication.

Establish a plan to ensure that future systems support the functionality needed to effectively oversee and manage the background investigation process, including addressing limitations identified in the current systems and incorporating the fields necessary to track timeliness metrics.

The assistant secretary for information and technology and chief information officer develop and approve an authorization to operate for the special-purpose system.

The assistant secretary for information and technology and chief information officer include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.

The VA medical center director install uninterruptible power supplies to eliminate single points of electrical failure supporting the facility.

The VA medical center director validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The VA medical center director implement media sanitization methods in accordance with VA policy requirements.

Issue guidance clarifying that allergens are exempt from the public law and include how the determination was reached.

Formalize and communicate the process for manufacturers to request exemptions.

Formalize the internal process for granting exemptions.

Establish a procedure for monitoring covered drugs identified in this report as not commercially sold.

Develop a procedure to monitor covered drugs identified in this report as newly launched to ensure they have an established ceiling price, and make certain they are made available on the Federal Supply Schedule at the end of the 75-day period.

Request that noncompliant manufacturers identified by the Office of Inspector General conduct a self-audit and submit their findings for remediation.

Engage with the Food and Drug Administration to ensure that when manufacturers request new national drug codes, they are made aware of the public law requirements.

Require contracting staff at the National Acquisition Center to conduct a covered drug check for all of a manufacturer’s drugs when any pharmaceutical Federal Supply Schedule proposal or product addition modification is submitted.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct comprehensive environment of care inspections at the required frequency

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.

The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation within the required time frame for patients with a positive suicide risk screen.

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

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures peer reviewers consistently document at least one of the nine aspects of care for Level 3 peer reviews.

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

The Director determines the reasons for noncompliance and ensures police document their response times to panic alarm testing in the mental health inpatient unit.

The Chief of Staff or Associate Director, Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures cameras used for patient safety monitoring do not record.

The Chief of Staff and Associate Director, Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure staff minimize risks of patients’ self-harm in the mental health inpatient unit.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff attempt weekly follow-up until mental health care is established for patients determined as intermediate or high-acute or chronic risk of suicide on the Comprehensive Suicide Risk Evaluation who are discharged home from the Emergency Department.

Develop and implement procedures to ensure the Veteran Readiness and Employment Service has properly researched and clearly understands changes to the laws and regulations that govern Chapter 31–only schools and training programs.

Review the existing manual requirements for waivers and coordinate with appropriate officials to ensure amendments to 38 United States Code § 3104(b) have been properly implemented and included in the manual.

Train all appropriate Veteran Readiness and Employment Service regional office staff to ensure waivers are obtained for each veteran with the required documentation in accordance with the manual before approval to attend a Chapter 31–only school or training program.

Coordinate with appropriate officials to determine whether the existing manual guidance for compliance surveys meets the requirements of 38 United States Code § 3693 as it applies to Chapter 31–only schools and training programs, and if necessary, update the manual and train appropriate Veteran Readiness and Employment Service regional office staff accordingly.

Develop and implement monitoring processes—to include veteran waivers, compliance surveys, and completeness of electronic folders—to provide Veteran Readiness and Employment Service reasonable assurance that Chapter 31–only schools and training programs are used as intended by law and regulations.

The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of the patient and third-party contacts, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

The Veterans Crisis Line Director expedites the alignment of the Medora documentation template with the VA and Department of Defense Clinical Practice Guideline and Veterans Crisis Line guidelines for suicide risk assessment classification levels.

The Veterans Crisis Line Director ensures and strengthens the quality management oversight of staff who provide crisis management services, including overtime coverage.

The Veterans Crisis Line Director confirms the retention of crisis management text conversations and establishes supervisory oversight protocols.

The Veterans Crisis Line Director ensures issue briefs accurately reflect the action plan.

The Veterans Crisis Line Director identifies criteria for immediate internal reviews of customers’ deaths by suicide and accidental overdose to identify crisis management and administrative performance improvement actions.

The Veterans Crisis Line Director conducts a full review of the patient’s text contact, determines whether an institutional disclosure is warranted, and takes action as indicated.

The Veterans Crisis Line Director monitors compliance with the submission and oversight of notification of a customer’s death, including timely submission of a suicide prevention coordinator consult.

The Veterans Crisis Line Director conducts a review of the interactions between the Director, Quality and Training, and staff in preparation and during the Office of Inspector General healthcare inspection, educates staff on the importance of fully cooperating, responding in an open and transparent manner, and avoiding any appearance of coordination between employees, and take actions as warranted.

The Veterans Crisis Line Director clarifies and strengthens procedures for complaint submission, provides staff training, ensures consistency with the Veterans Health Administration directive, and monitors compliance.

The South Texas Veterans Health Care System Director ensures that processes are established for timely death notification entry in patients’ electronic health records.

The South Texas Veterans Health Care System Director ensures that staff adheres to the January 2022 standard operating procedures for administrative and clinical actions following a patient’s or employee’s death by suicide.

The Veterans Crisis Line Director strengthens processes to ensure discontinuation of caring letters in a timely manner following notification of a patient’s death.

The South Texas Veterans Health Care System Director makes certain that the Suicide Prevention Program ensures full implementation of the Behavioral Health Autopsy Program as required by the Veterans Health Administration.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs’ reprivileging recommendations are based, in part, on Ongoing Professional Practice Evaluation activities.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee considers professional practice evaluation results in decisions to recommend privileges.

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures staff complete Comprehensive Suicide Risk Evaluations.

The under secretary for health to make sure all scheduling guidance and other materials correctly refer to the date that should be used to determine wait-time eligibility for community care.

The under secretary for health to make sure the Office of Integrated Veteran Care provides ongoing oversight to ensure all facilities are using nationally approved scheduling tools.

The under secretary for health to develop an oversight process to verify that schedulers are using the correct dates to calculate wait-time eligibility for community care.

The under secretary for health to develop a mechanism to notify schedulers when it is appropriate to consider wait-time eligibility for community care regardless of which scheduling system schedulers are using.

The under secretary for benefits update the instructions provided to examiners for completing Gulf War general medical examinations to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317 and clarify the instructions and related procedures to reflect that an examiner’s determination that a disability pattern is an undiagnosed illness or a medically unexplained illness requires a written explanation.

The under secretary for benefits implement a plan to update the Gulf War general medical examination disability benefits questionnaire to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317.

The under secretary for benefits implement a plan to incorporate into the Gulf War general medical disability benefits questionnaires the clinical requirements listed in 38 C.F.R.§ 3.317 for an undiagnosed illness and a medically unexplained illness.

The under secretary for benefits implement a plan to incorporate into the appropriate medical disability benefits questionnaires the diagnostic criteria for functional gastrointestinal disorders from 38 C.F.R.§ 3.317 and require examiners to provide an explanation of whether the disorder is functional or structural. This should include a requirement that any necessary testing has been completed before examiners diagnose specific functional gastrointestinal disorders.

The under secretary for benefits update VA’s Adjudication Procedures Manual to clearly state that all the requirements of 38 C.F.R.§ 3.317 must be met to award benefits. Clarify and reiterate instructions to claims processors that benefits should only be awarded after taking into consideration the overall evidence of record.

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.