All Reports

Date Issued
|
Report Number
22-00811-07

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that chiefs of staff and associate directors for patient care services ensure all required members attend disruptive behavior committee or board meetings.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that chiefs of staff ensure disruptive behavior committees or boards document patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2025

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that medical center directors ensure staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.

Date Issued
|
Report Number
22-00813-253
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Date Issued
|
Report Number
21-00797-248
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2024

The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2024

The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.

Date Issued
|
Report Number
21-02641-229
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Topics:  Leases and Major Contracts

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 8/15/2024

Assess compliance weaknesses identified by VA Office of Procurement Policy, Systems and Oversight internal reviews, and implement corrective actions determined appropriate.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/23/2024

Require contracting officers responsible for Buy American Act compliance deficiencies identified by contract file reviewers and VA Office of Procurement Policy, Systems and Oversight internal reviews to attend refresher Buy American Act–specific training.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2023
Evaluate the contract file review procedures to make certain they require the use of the Definitions of Comment Categories, and presolicitation and preaward checklists, and document that use, to strengthen compliance.
Date Issued
|
Report Number
22-00973-215
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/3/2023
Implement a more effective process to maintain consistent inventory information for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/3/2023
Implement a vulnerability management program that ensures system changes occur within organization timelines.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/23/2023
Implement effective system life-cycle processes to ensure network devices meet standards mandated by the VA Office of Information and Technology Configuration Control Board.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/27/2022
Develop and implement a process to retain database logs for a period consistent with VA’s record retention policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/22/2024

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

Date Issued
|
Report Number
21-03203-239
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2024

The Southeast Network Director facilitates a comprehensive review of Patient A’s episode of care, from the time and date of the patient’s hospitalization through the date and time of the patient’s death, to identify practitioner and process improvements that may reduce the potential for future incidents, and takes appropriate actions.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
The Columbia VA Health Care System Director ensures providers carefully consider facility resources when evaluating medically-complex patients for admission and when determining whether admitted patients’ medical complexities exceed the facility’s capabilities to meet patients’ needs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2023
The Columbia VA Health Care System Director ensures that the peer review committee record the committee members formal discussions specific to the peer review in meeting minutes, and monitors ongoing compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
The Columbia VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, ensures current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2023
The Columbia VA Health Care System Director ensures that root cause analyses are completed within the required 45-day time frame to promptly identify and address system vulnerabilities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/2/2023
The Columbia VA Health Care System Director facilitates a comprehensive administrative review of the vascular surgeon’s disregard of surgical and invasive procedure protocols and Stop the Line principles, consults with the Office of Regional Counsel and human resource specialists, and takes administrative actions, as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
The Columbia VA Health Care System Director evaluates facility staff’s informed consent and time-out practices, to include the review of pertinent medical images, and ensures practices are consistent with correct surgery and invasive procedure requirements, takes action as appropriate, and monitors compliance.
Date Issued
|
Report Number
21-02145-243
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Topics:  VA Police

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
Ensure the director of the Office of Operations, Security, and Preparedness creates a written policy establishing minimum standards for ballistic armor for Executive Protection Division personnel based on agents’ input, industry best practices and research, and relevant threat levels, which is routinely reassessed for adequacy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
Make certain that the director of the Office of Security and Law Enforcement develops onboarding procedures for new Executive Protection Division personnel who are or may be assigned to protective details or motorcades of the VA Secretary or Deputy Secretary, including procedures for measuring personnel and procuring new ballistic vests or assessing and approving the use of an employee’s own vest to ensure it meets minimum safety standards.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
Require the director of the Office of Security and Law Enforcement to establish procedures to track the maintenance and expiration of ballistic vests assigned to Executive Protection Division personnel and to ensure their replacement as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
Instruct the director of the Office of Security and Law Enforcement to create procedures for monitoring compliance with the standard operating procedure requirement to wear ballistic armor, such as periodic inspections, and establish consequences for noncompliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/16/2023
The OIG recommends that the director of the Office of Security and Law Enforcement conducts a review of the condition of all firearms currently assigned to EPD special agents and determines whether any are in need of replacement.
Date Issued
|
Report Number
21-03906-226
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Topics:  Patient Care Services Operations

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2025

Coordinate with the Prosthetic and Sensory Aids Service executive director to (1) develop and issue guidance clearly articulating eligibility requirements for the lifetime benefit amounts to address non-service-connected disabilities and (2) communicate this guidance in an effective manner, such as including specific language in handbooks, providing examples of scenarios to reinforce the requirements, and requiring annual training to make sure all prosthetic staff responsible for the program understand these eligibility requirements.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2023
Coordinate with the Prosthetic and Sensory Aids Service executive director to make sure Veterans Integrated Service Network prosthetic representatives look at veteran eligibility for non-service-connected disability benefits in their annual reviews of medical facilities’ prosthetics programs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
Coordinate with the Prosthetic and Sensory Aids Service executive director to correct and update inaccurate information on the publicly accessible Home Improvements and Structural Alterations Program website.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2023
Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to make sure medical facilities or Veterans Integrated Service Networks implement procedures for verifying that veterans’ Home Improvement and Structural Alterations packages include documentation of approval and justification for all improvements and alterations paid for with program benefits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2024

Coordinate with the assistant under secretary for health for operations and the Prosthetic and Sensory Aids Service executive director to ensure medical facilities and Veterans Integrated Service Network directors implement procedures to capture when key documentation is received and monitor these dates to ensure facilities adhere to timelines for the Home Improvements and Structural Alterations Program and take corrective action when they are not meeting standards outlined in 38 C.F.R. §§ 17.3100 through 17.3130 and VHA Directive 1173.14.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 13,798,444.00
Date Issued
|
Report Number
22-00971-217
|
Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Implement a more effective process to maintain consistent inventory information for all network segments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Improve the vulnerability and flaw remediation program to accurately identify vulnerabilities and enforce flaw remediation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/17/2023
Implement effective configuration control processes that ensure network devices maintain vendor support.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/28/2025

Perform security control assessments of the video surveillance system and obtain an authorization to operate in accordance with set policy.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/25/2023
Ensure installation of distributed network infrastructure equipment that meets VA installation standards, to include proper equipment mounting and clearance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Ensure routine maintenance is conducted on uninterruptible power supplies.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/22/2022
Implement database authentication processes that comply with VA security requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/17/2023
Implement a physical access control system for the data center and core switch room that is supportable and can meet VA logging requirements.
Date Issued
|
Report Number
21-00887-211
|
Topics:  Maintenance and Construction

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The director of Veterans Integrated Service Network 2 should ensure useful life assessments are conducted for those boilers operating past their expected or extended lifespans outlined in this report to ensure safe operation. 23
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The director of the Office of Healthcare Engineering should clarify policies and procedures for scheduling useful life assessments of boilers prior to the end of expected lifespans and after an extension has been granted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The director of the Office of Healthcare Engineering should update VHA Directive 1810 to ensure that medical facility boiler policies are updated to reflect site-specific safety device testing procedures, including justifications for each test prescribed in the VHA Boiler and Associated Plant Safety Device Testing Manual that the medical facility does not plan to perform.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The director of the Office of Healthcare Engineering should update VHA Directive 1810 to clarify which tests and inspections require the use of third-party inspectors, as well as the frequency of these tests and inspections.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2023
The director of Veterans Integrated Service Network 2 should review medical facilities’ boiler operation policies to ensure procedures for notifying management and documenting corrective action plans and timelines for addressing safety incidents are consistent with VHA Directive 1810 requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The director of Veterans Integrated Service Network 2 should employ a management information system to ensure all individuals with oversight responsibility are granted access to records for boiler maintenance deficiencies and corresponding corrective actions, boiler inventory, testing and inspection compliance, and useful life assessment completeness.
Date Issued
|
Report Number
22-00815-232
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Topics:  Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff ensure that transferring providers send patients’ active medication lists and copies of advance directives to receiving facilities during inter-facility transfers.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff and associate directors of patient care services ensure nurse-to-nurse communication occurs during the inter-facility transfer process.

Date Issued
|
Report Number
21-02326-233
|
Topics:  Community Care ● Care Coordination ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2023
The Veterans Health Care System of the Ozarks Facility Director ensures that Office of Community Care staff take action on active consults within seven days and schedule community care appointments within the 30-day clinically indicated date requirement and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/7/2023
The Veterans Health Care System of the Ozarks Facility Director evaluates the process for authorization of requests for community care and for coordinating care for patients receiving oncology treatment in the community, and takes corrective action to address any deficiencies identified.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2023
The Under Secretary of Health ensures the Veterans Health Administration Office of Community Care defines a standardized process for community care coordination related to follow-up requests for additional services from community providers.
Date Issued
|
Report Number
22-00404-207
|
Topics:  Claims and Medical Exams

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/23/2023

Implement electronic system enhancements to require claims processors to identify relevant evidence before a medical opinion request can be submitted.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/24/2023
Enhance mandated training for all claims processors on making medical opinion requests and demonstrate progress showing that the training is achieving its intended impact.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/29/2024

Strengthen monitoring controls by improving the national and local quality review processes to identify medical opinion request areas in need of improvement and demonstrate progress toward ensuring compliance with established procedures.

Date Issued
|
Report Number
22-00208-221
|
Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Require the finance office to perform quarterly compliance reviews of pharmacy invoice reconciliations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Develop a plan to work with the prime vendor to address having adequate stock to meet orders, reducing the need for the healthcare system to use nonprime vendors.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Ensure the healthcare system submits Medical/Surgical Prime Vendor–Next Generation waiver requests and obtains approval before purchasing available formulary items from nonprime vendor sources.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2023
Ensure logistics staff and the contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance concerns and challenges.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2023
Develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2023
Develop and implement a plan to increase inventory turnover to the Veterans Health Administration‑recommended level.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2023
Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items in compliance with Veterans Health Administration policy.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,940.00
Date Issued
|
Report Number
22-00814-230
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures healthcare providers inform patients and/or caregivers when a medication is not FDA-approved; provide the option to refuse the medication; and advise them of the known risks, benefits, and alternatives prior to administration.