All Reports

The Veterans Integrated Service Network Director evaluates the role of the Patient Safety/ Risk Management Subcommittee to determine the degree to which the subcommittee will address facility level performance with Patient Safety Program activities and tracking of action plans when a deficiency is identified, and updates the subcommittee charter as warranted.

The Under Secretary for Health evaluates the process for programmatic oversight by VA’s National Center for Patient Safety over Veterans Integrated Service Networks’ and facilities’ patient safety programs.

Conduct an all-personnel audit of Beckley VA Medical Center staff to ensure background investigation requirements were met, to include considering an all-personnel data match of relevant suitability records against comparable datasets from the Personnel Investigations Processing System, and report results to the Workforce Management and Consulting office for verification.

Establish a project management plan to conduct compliance checks at other Veterans Integrated Service Network 5 facilities and share the plan with other networks.

Evaluate staffing levels for the personnel suitability program and allocate staff as needed to meet VA timelines.

The Secretary of Veterans Affairs delegates to a responsible official the monitoring of VA facilities’ security-related vacancies and reports monthly on hiring trends and whether recent recruitment and hiring authorities established since the fiscal year 2021 Police National Strategic Recruitment Plan are resulting in improvements.

The Secretary of Veterans Affairs authorizes sufficient staff for the Human Resources and Administration/Operations, Security and Preparedness’ Office of Security and Law Enforcement to inspect the VA police forces, per the OIG’s 2018 unimplemented recommendation.

The under secretary for health ensures medical facility directors use appropriate measures to assess VA police staffing needs, authorizes associated positions, and leverages available mechanisms to fill vacancies.

The under secretary for health verifies that medical facility directors commit sufficient resources to make certain that facility security measures are adequate, current, and operational.

The under secretary for health directs Veterans Integrated Service Network police chiefs, in coordination with medical facility directors, facility police chiefs, and facility emergency management leaders, to present a plan to remedy identified security weaknesses, including inoperative cameras, unsecured doors, and the lack of security presence at main entrances.

The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness establishes policy that standardizes the review and retention requirements for footage captured by facility security cameras.

The Medical Center Director determines any additional reasons for noncompliance and makes certain the Comprehensive Environment of Care Coordinator or designee schedules and ensures completion of environment of care inspections in patient care areas at the required frequency or maintains documentation to support pandemic-related postponement.

Ensure that healthcare system finance office staff and initiating services are made aware of policy requirements to conduct reviews on all inactive open obligations and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”

Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.

Develop a control to ensure required supporting documentation is received from vendors that ship directly to veterans.

Ensure all supplies are entered into the Generic Inventory Package as required by Veterans Health Administration policy.

Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package per Veterans Health Administration policy.

Ensure supply chain management staff implement a plan for staff training to increase awareness of internal controls and data reliability within the Generic Inventory Package.

Ensure the chief of supply chain services signs quarterly physical inventory memorandums of “A” classified items and make them available to Veterans Integrated Service Network personnel as required in the Veterans Health Administration’s Directive 1761 Supply Chain Management Operations.

Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.

Develop and implement a plan to complete monthly B09 reconciliation consistently to ensure discrepancies are corrected in a timely manner.

The Overton Brooks VA Medical Center Director evaluates the processes for the communication of abnormal radiology imaging results and ensures patients receive timely notification, per Veterans Health Administration and facility requirements.

The Overton Brooks VA Medical Center Director ensures oversee all clinical decisions and documentation made by residents and the oversight is reflected within the documentation.

The Overton Brooks VA Medical Center Director reviews the processes for assigning a provider surrogate and monitors compliance.

The Under Secretary for Health ensures that Veterans Integrated Service Network leaders provide adequate oversight to ensure adherence to the mental health residential rehabilitation treatment program access to care policy as required.

The Under Secretary for Health ensures the Office of Mental Health and Suicide Prevention develops, implements, and monitors action plans to meet Intensive Community Mental Health Recovery visit frequency requirements, to include program resource needs and the ongoing role for virtual care.

The Under Secretary for Health requires the Office of Mental Health and Suicide Prevention to develop a process for Intensive Community Mental Health Recovery programs to ensure veterans receiving low-intensity services do not represent greater than 20 percent of caseloads and to distinguish between veterans receiving high- and low-intensity services for accurate and effective program oversight.

The Under Secretary for Health identifies barriers and ensures healthcare systems develop, implement, and maintain contingency plans specific to Intensive Community Mental Health Recovery programs regarding veteran access to medications during emergencies, including long-acting injectable antipsychotic medications.

The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.

The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.

The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.

The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.

The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.

The North Las Vegas Medical Center Director ensures a review is conducted of the primary care provider’s electronic health record documentation in order to determine if blood pressure entries other than 120/80 are false and takes action as necessary.

The North Las Vegas Medical Center Director ensures that any identified false blood pressures are amended in the electronic health record in accordance with Veterans Health Administration policy.

The VA Maryland Health Care System Director ensures that Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints.

The VA Maryland Health Care System Director evaluates and strengthens the process to ensure that problem lists reflect current and active diagnoses, and takes action as necessary.

The Veterans Integrated Service Network Director reviews the supervision provided to the psychiatry trainee regarding the patient’s treatment, documentation, and document control, to include electronic health records and video recordings, and determines if standards were met, and takes action as indicated.

The Greater Los Angeles Healthcare System Director reviews the facility leader and staff responses, including those of the supervisor and patient advocate, to ensure the patient’s concerns were adequately addressed, and takes action as indicated.

The Greater Los Angeles Healthcare System Director ensures records control schedules, including one for video recordings, are completed for the Mental Health Department as required by Veterans Health Administration policy.

The Greater Los Angeles Healthcare System Director reviews processes related to the utilization of video recordings, in consultation with appropriate staff, to ensure compliance with Veterans Health Administration requirements.

The District Director determines reasons clinical quality review remediation plans at the four selected vet centers did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.

The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Cleveland, Columbus, and Toledo Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Cleveland, Columbus, and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance

The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution for the Columbus and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

The Readjustment Counseling Service Chief Officer defines “serious suicide attempt” and establishes criteria for when a morbidity and mortality review is required as well as a standardized process for completing the review.

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

The District Director ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required, and monitors compliance across all zone vet centers.

The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider to include the suicide prevention coordinator following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.

The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk-suicide flag or clients with an increased predictive risk for suicide at the Columbus, South Bend, and Toledo Vet Centers, takes action to ensure requirements are met, and monitors compliance.

The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures vet center directors implement processes, and monitors compliance.

The District Director determines reasons staff at the Cleveland, Columbus, South Bend, and Toledo Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.

The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors complete suicide risk assessments and assign risk levels based on client risk factors, reevaluate levels when risk factors change, and monitors staff’ compliance.

The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors consistently mitigate clients’ risk for suicide, as appropriate, by developing personalized safety plans, seeking clinical consultation, increasing client contact efforts, and completing crisis reports, and monitors compliance.

The Midwest District 3 Director ensures that when clients are transferred from one counselor to another, relevant clinical information is communicated, applicable safety measures are in place, services are not disrupted, and when possible, a joint session with the outgoing and incoming counselor is held with the client.

Ensure vulnerabilities are remediated within established time frames.

Develop and approve a system security plan and an authorization to operate for the special-purpose system.

Verify that access control lists have been applied to network segments that contain medical systems.

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The Richard L. Roudebush VA Medical Center Director ensures that staff conduct and document focused professional practice evaluations as required by Veterans Health Administration.

The Richard L. Roudebush VA Medical Center Director ensures timely completion of factfinding reviews to promptly identify and address system vulnerabilities.