All Reports

Strengthen controls in the Office of the Assistant Director to ensure inclusion of staffing monitoring contract requirements, in coordination with the contracting officer, to meet gradual staffing level goals during start-up periods in future community‑based outpatient clinic contracts.

Strengthen controls to ensure data used for monitoring contract performance standards are accurate and comply with the methodology required in the contract’s Quality Assurance Surveillance Plan.

Review the medical staff-driven phase of the credentialing process, to ensure action plans implemented to expedite the credentialing process are effective.

Strengthen controls to ensure contracted staff complete required scheduling training before granting them access to VA’s scheduling system and authorizing them to make veteran appointments.

Review the healthcare system’s staffing augmentation plan and coordinate with the contracting officer to ensure the full costs are recovered for all Veterans Health Administration staff who provided services for which the contractor was also compensated.

Review the unilateral memorandum related to staffing augmentation, establish a contract modification in compliance with the Federal Acquisition Regulation provisions regarding contract changes, and ensure relevant documentation is maintained in the contract file.

Recover government funds expended for Veterans Health Administration staff augmented at contracted community-based outpatient clinics using full cost amounts.

Review and enforce staffing contingency plan requirements for the Loma Linda Healthcare System contract, including maximizing the contractor’s use of temporary replacements, or locum tenens, to minimize staffing shortages.

Strengthen oversight mechanisms to ensure the enforcement of staffing requirements during contract start-up in future community‑based outpatient clinic contracts before the clinics become operational.

Implement procedures to monitor the data used to measure productivity to ensure the data accurately reflect the complete work of clinical resource hub physicians.

Work with appropriate officials, such as Office of Primary Care and clinical resource hub leaders, to determine whether hub physicians should be subject to existing productivity measures. If so, issue clear hubs guidance requiring adherence; if not, clearly define what should be used, and issue thorough guidance on the steps hubs must take to measure physician productivity consistently.

Clarify oversight responsibilities for monitoring productivity measures, including detailed procedures and actions that should be taken when thresholds are not met.

The VA Fayetteville Coastal Healthcare System Director reviews the endocrine consult management process and takes actions as needed to ensure compliance with current Veterans Health Administration directives and guidance.

The VA Fayetteville Coastal Healthcare System Director implements a strategy to review patients affected by delayed endocrine consults to evaluate whether harm occurred and the appropriateness of institutional disclosures.

The VA Fayetteville Coastal Healthcare System Director ensures a sustainable and effective service line agreement between endocrine and primary care services is developed and agreed upon by both services, and monitors implementation.

The VA Fayetteville Coastal Healthcare System Director confirms effective utilization of endocrine clinic appointments to ensure timely access to care.

The VA Fayetteville Coastal Healthcare System Director ensures a process is in place for monitoring and tracking clinic profile modification requests.

The VA Mid-Atlantic Health Care Network Director reviews the leadership performance of the chief of medicine related to communication and collaboration and takes action as necessary.

The VA Fayetteville Coastal Healthcare System Director evaluates communication gaps identified in this report between leaders of primary care and the Medicine Service and takes action to ensure consistency with Veterans Health Administration High Reliability Organization goals.

Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.

The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.

The Medical Center Director ensures an environment of care committee meets, as required.

The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.

The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.

The Medical Center Director ensures the emergency management plan includes guidance for managing shelter-in-place supplies.

Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.

The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.

Executive leaders ensure staff complete improvement actions from root cause analyses within one year.

The Under Secretary for Health ensures that VA homeless program staff consistently document, in patients’ electronic health records, the clinical information from the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that a suicide risk screening is completed with patients during intake into VA homeless programs, consistent with Veterans Health Administration policy.

The Under Secretary for Health ensures that staff complete suicide risk screening in response to danger of self-harm identified in the Homeless Operations Management and Evaluation System.

The Under Secretary for Health makes certain that homeless program staff provide and document care coordination to address patients’ mental health and substance use disorder treatment needs as identified in the Homeless Operations Management and Evaluation System.

Facility leaders ensure providers who order tests communicate the results to patients timely.

Ensure the Palo Alto major construction project (project number 640-424) is brought into the Acquisition Program Management Framework.

Ensure the activities and artifacts required during the verify phase of the Acquisition Program Management Framework are completed for the Palo Alto major construction project (project number 640-424)—including a business case with cost, schedule, and performance goals approved by the Secretary.

Ensure a decision event to verify the need of the acquisition is conducted for the Palo Alto major construction project (project number 640-424) and a determination is made to terminate or continue this project based on VA’s strategic needs and the VA Palo Alto Health Care System’s clinical needs.

Ensure VA’s FY 2025 Agency Capital Plan is revised to show the Palo Alto major construction project’s current total estimated cost and the progress the project has made toward meeting its critical objectives.

Ensure processes and guidance are in place for the director of the Office of Construction and Facilities Management to provide appropriate oversight and management over minor construction projects consistent with the authority and responsibilities described in 38 U.S.C. § 312A.

Revise the Veterans Health Administration directive on minor construction projects to incorporate 38 U.S.C. § 312A requirements and develop a review process for confirming compliance with the Office of Construction and Facilities Management’s guidance and any applicable industry standards.

Review the Audie L. Murphy emergency department exam and fast-track rooms for compliance with applicable design and equipment standards and provide any recommendations to the executive director of the South Texas Veterans Health Care System.

Review an assessment by the Office of Construction and Facilities Management of the Audie L. Murphy’s emergency department for compliance with design and equipment requirements to determine what changes, if any, are necessary and take appropriate corrective action.

The facility Director ensures staff review primary care panel sizes and capacity levels to ensure they are accurate.

Reassess and clarify physical inventory requirements for equipment in medical facilities to ensure they are consistent with and meet the intent of VA Directive 7002.

Ensure that facility directors require custodial officers to regularly review nonexpendable inventory to determine whether the equipment is required and take appropriate action.

Ensure medical facility directors review inventory list compliance data to identify noncompliant services and implement a process to resolve noncompliance.

Ensure the Veterans Health Administration’s Procurement and Logistics Office, in coordination with VA’s Office of Acquisition and Logistics, regularly monitors inventory compliance data to identify and communicate with noncompliant facilities to proactively address delinquent inventories.

Require medical facilities to use a standardized report of survey dashboard to centrally report all lost, stolen, or damaged items.

Require medical facility directors to review inventory compliance and establish a process to ensure noncompliant equipment—to include equipment identified in this audit—is reported as lost, stolen, or damaged within required time frames.

Reiterate through formal communication that facilities and regional Veterans Integrated Service Networks are required to fully implement and use the Strategic Equipment Planning Guide and Enterprise Equipment Request process for equipment planning and approval and develop a system to monitor compliance and verifying facilities are using the process as required.

Ensure relevant staff complete training on the Strategic Equipment Planning Guide and Enterprise Equipment Request process that explains user roles and responsibilities.

Ensure facilities define and assign Strategic Equipment Planning Guide and Enterprise Equipment Request user roles and responsibilities as applicable.

Reiterate through the formal communication advised in recommendation 1 that the Strategic Equipment Planning Guide and Enterprise Equipment Request process are required for all equipment planning and approval—and clearly define whether there are any exceptions.

Specify when and which equipment purchases require review and approval by additional subject matter experts.

Ensure a disability compensation examiner who has completed PACT Act training provides an independent assessment and medical opinion for the 29 VHA and five VBA nonpresumptive PACT Act opinions identified by the Office of Inspector General that were provided before completing PACT Act training, and readjudicate the claims as needed.

Establish and use agreements with other VA medical facilities to help identify and schedule direct care when services are unavailable at a veteran’s local VA facility.

At least annually, emphasize to schedulers the proper methods (including the use of codes) to document when veterans opt out of community care.

Require the medical facility director at the Jesse Brown VA Medical Center in Chicago to make sure veterans who request mental health services are assessed for community care and informed of all potential care options.

Require medical facility directors in Veterans Integrated Service Network 12 to review and process consults initiated in the first quarter of fiscal year 2024 that remain in a pending, active, or scheduled status.

The principal executive director of the Office of Acquisition, Logistics, and Construction considers whether any additional training or other measures are necessary with respect to reporting the wrongdoing of a supervisor and the acceptance of free meals and drinks by VA employees during the February 2023 site visit.

The principal executive director of the Office of Acquisition, Logistics, and Construction determines whether any additional guidance, training, or oversight is needed with respect to ensuring VA employees do not improperly solicit sponsorships for VA events that do not primarily benefit veterans.

VA’s designated agency ethics official determines whether any additional steps need to be taken in connection with Ms. Dawson’s 2023 public financial disclosure based on the findings of this report.

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

Facility leaders ensure each service has a service-level workflow for test result communication that is consistent with VHA requirements.

The Director ensures the Chief of Staff attends Peer Review Committee meetings.