All Reports

The Network Director evaluates and determines additional reasons for noncompliance and submits a Comprehensive Environment of Care compliance report to the Environment of Care Committee annually.

The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Emergency Management Committee conducts an annual review of the Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and documents it in writing.

Ensure medical facilities monitor resilient high-frequency radio network training and staffing levels and maintain enough trained staff to operate the resilient high-frequency radio network.

Ensure that the appropriate stakeholders know the program office responsible for the resilient high-frequency radio network and understand the roles and responsibilities for the Veterans Health Administration’s Resilient High-Frequency Radio Network program.

Finalize the Veterans Health Administration High-Frequency Radio Operations Plan.

Conduct a risk assessment and provide guidance for the placement of resilient high-frequency radio networks within facilities and any needed monitoring schedules.

Ensure sites can obtain repairs for broken or inoperable resilient high-frequency radio network equipment.

The West Palm Beach VA Healthcare System Director ensures that pulmonary providers communicate and document test results and surveillance care plans to patients.

The West Palm Beach VA Healthcare System Director ensures that pulmonary providers and staff are trained on the use of return-to-clinic orders and monitors for compliance.

The West Palm Beach VA Healthcare System Director ensures that chiropractor providers review community care notes and takes action as needed.

The Richard L. Roudebush VA Medical Center Director considers establishing written procedures for discharge planning in the Emergency Department, including documentation of contact with family members regarding notification of discharge and follow-up when applicable.

The Richard L. Roudebush VA Medical Center Director expedites written guidance for primary care staff’s care coordination of patients discharged from the Emergency Department including documentation expectations and oversight responsibilities, and monitors compliance.

The Richard L Roudebush VA Medical Center Director establishes a protocol for the administrative staff management of potentially urgent patient care needs, ensures training, and monitors compliance.

Implement controls to mitigate the risk that data are unreliable and inconsistently recorded between eCMS and iFAMS when staff deobligate funds for converted contracts.

Establish and implement a methodology to prioritize user feedback into the risk management process.

Ensure that converted contracts are included in integrated system testing and user acceptance testing.

Implement a process that provides formal acknowledgment on whether requests related to high-priority business intelligence reports have been accepted as requirements.

Take action to help reduce unwarranted reexaminations by updating guidance and enhancing information systems to require rating specialists to cite objective evidence and provide justification for establishing reexamination controls.

Consider establishing criteria to define a “locally-designated claims processor with expertise in review examination ordering” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations.

Update training materials to include the guidance from VBA Policy Letter 21-01, “Updated Guidance on Routine Future Examination Requests” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance using objective criteria accepted by the practitioner.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews and evaluates licensed independent practitioners’ privileging requests and documents its review in the meeting minutes.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete Focused Professional Practice Evaluations and document results in practitioners’ profiles.

The executive director for the Veterans Health Administration Office of Integrity and Compliance implements planned revisions of policies and procedures for the Office of Integrity and Compliance to ensure it performs accurate List of Excluded Individuals and Entities monitoring, including for individuals with alternative or prior names or using social security numbers (if accessible), and provides timely notification of potential violations to appropriate staff.

The executive director for the Veterans Health Administration (VHA) Office of Integrity and Compliance performs a one-time audit of VA employment records using corrected matching practices to determine whether any individuals on the List of Excluded Individuals and Entities are receiving payments using VA healthcare program funds, and, if so, whether additional revisions to policies and procedures of the VHA Office of Integrity and Compliance, the VHA Office of Human Capital Management, or any other element of VA are required to address the causes, including any related screening and/or monitoring process failures.

Ensure DROCs identify which raters meet all the requirements to issue decisions on complex appeals, and to communicate to managers and staff which raters meet those requirements.

Provide guidance to DROC supervisors on how to maintain VBMS routing rules, and have OAR establish a procedure to periodically ensure WIT and workload designations at the DROCs are in alignment.

Ensure the St. Petersburg DROC monitors the effectiveness of its modified procedures that only designated DROs are assigned informal conferences for complex appeals, and ensure complex appeal designation will be accounted for in future informal conference routing applications.

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.