All Reports

Deficiencies in the Care of a Patient with Gastrointestinal Symptoms at the Eastern Oklahoma Health Care System in Muskogee
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21-01801-45
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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: 5/24/2023
The Eastern Oklahoma VA Health Care System Facility Director reviews processes to ensure patients with ordered Fecal Immunochemical Test (FIT) are tracked according to Veterans Health Administration policy, documentation is complete, and takes action if necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Eastern Oklahoma VA Health Care System Facility Director evaluates processes for Emergency Department providers’ physical examinations when a patient presents with gastrointestinal symptoms that include associated bleeding and determines if modifications, including provider education, are needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2022
The Eastern Oklahoma VA Health Care System Facility Director ensures that patient advocates and Primary Care leaders perform thorough reviews of all components of complaints for resolution and patient advocates document according to policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Eastern Oklahoma VA Health Care System Facility Director ensures facility leaders monitor complaints and take action on issues that are identified related to the Emergency Department physician’s performance.
Financial Efficiency Review of the Eastern Oklahoma VA Health Care System
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21-00942-16
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure finance office staff are made aware of policy requirements and reviews are conducted on all open obligations as required by VA Financial Policies and Procedures, vol. 2, chap. 5, “Obligations Policy,” January 2018.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of contracting for Network Contracting Office 19, VA Rocky Mountain Network, develop checks on the successful completion of quarterly audits of the purchase card program as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/31/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interests of the government.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop measures to confirm completed VA Form 0242 submissions are accurate and updated for all cardholders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop formalized processes for 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: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to complete facility based inventory audits of noncontrolled drug line items in compliance with VHA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish measures to improve compliance with the nonformulary request process.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 95,000.00
Improvements Needed to Ensure Final Disposition of Unclaimed Veterans’ Remains
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19-09592-262

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Enterprise Integration (OEI)
Closure Date: 4/26/2023
The OIG recommended the assistant secretary for the Office of Enterprise Integration designate a senior accountable official or program office for the full scope of benefits and services provided on behalf of deceased veterans whose remains are unclaimed. This official or office should be charged with ensuring that VA’s benefits and services for unclaimed veterans comply with applicable federal enterprise risk management and internal control standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Enterprise Integration (OEI)
Closure Date: 12/13/2022
The OIG recommended the assistant secretary for the Office of Enterprise Integration conduct a program evaluation of all VA benefits and services for deceased veterans whose remains are unclaimed in compliance with applicable laws and VA regulations. This evaluation should consider the extent to which existing law requires VA to conduct outreach on behalf of deceased veterans whose remains are unclaimed. This evaluation should also ensure the benefits and services are assigned to the appropriate VA program offices and the offices are given authority to administer these programs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Enterprise Integration (OEI)
Closure Date: 10/15/2024

The OIG recommended the assistant secretary for the Office of Enterprise Integration coordinate and implement data sharing agreements with other agencies or organizations with records of deceased veterans whose remains are unclaimed or veterans not included in VA databases.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Enterprise Integration (OEI)
Closure Date: 1/25/2023
The OIG recommended the assistant secretary for the Office of Enterprise Integration determine eligibility and take action to facilitate dignified burials for these persons with unclaimed remains whose records the OIG referred to VA.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Enterprise Integration (OEI)
Closure Date: 10/31/2022
The OIG recommended the assistant secretary for the Office of Enterprise Integration develop a comprehensive estimate of the number of deceased veterans whose remains are unclaimed awaiting burial, including those held at locations other than funeral homes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 8/10/2023
The OIG recommended the assistant secretary for management and chief financial officer implement controls for payments made to individual payees or other entities on behalf of deceased veterans whose remains are unclaimed that can be cross referenced across current VA payment systems and ensure that staff involved with issuing payments are trained in the correct use of these controls.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2022
The OIG recommended the under secretary for benefits implement monitoring mechanisms, procedures, and recurring training for VA regional office directors on their responsibilities for facilitating burials for deceased veterans whose remains are unclaimed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/3/2022
The OIG recommended the under secretary for benefits require points of contact for indigent and unclaimed veterans outreach to regularly complete the outreach functions listed in VA Manual 27 1, chapter 11. VBA should ensure points of contact receive recurring training in these tasks and implement ongoing compliance activities.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2023
The OIG recommended the under secretary for health direct VHA leadership to assess the extent to which personnel in the former VHA Office of Operations and Management and the VHA Office of Member Services were not performing required oversight activities and take appropriate action.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 8/3/2022
The OIG recommended the under secretary for memorial affairs implement system indicators in NCA systems to show when veterans’ remains are unclaimed without relying on a manually updated spreadsheet. These system indicators should enable tracking mechanisms to ensure required follow ups are performed on completed burial eligibility determinations without a scheduled interment and identify repeat burial eligibility requests.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 1/25/2023
The OIG recommended the under secretary for memorial affairs in coordination with the Secretary’s Center for Strategic Partnerships, assess options for providing a suitable casket or urn to a deceased veteran whose remains are unclaimed rather than a monetary reimbursement.
Follow-Up Review of the Accuracy of Special Monthly Compensation Housebound Benefits
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20-04219-07
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Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2022
Review all active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2022
Implement a plan to conduct ongoing periodic reviews of completed active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/16/2022
Update the special monthly compensation housebound training to include guidance on and examples of statutory, housebound in fact, individual unemployability, and extraschedular criteria, and monitor the effectiveness of the training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/27/2022
Create a system enhancement to limit the statutory special monthly compensation housebound validation warning to trigger only when statutory housebound criteria are met but not addressed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/23/2022
Create a system enhancement to prohibit rating veterans service representatives from bypassing statutory housebound validation warnings without taking action or providing justification.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2023

Correct all processing errors on cases identified by the review team and report the results to the OIG.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 136,000,000.00
Comprehensive Healthcare Inspection of the Hampton VA Medical Center in Virginia
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21-00278-23
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Topics:  Care Coordination ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that required members regularly attend Surgical Workgroup meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that appropriately privileged transferring providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to inter-facility patient transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Comprehensive Healthcare Inspection of the Fayetteville VA Coastal Health Care System in North Carolina
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21-00277-41
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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: 5/11/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Workgroup meets monthly and core members consistently attend meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The OIG recommends that the principal executive director, Office of Acquisition, Logistics, and Construction direct the Strategic Acquisition Center’s Medical/Surgical Prime Vendor Program contracting officer to provide guidance to Veterans Integrated Service Network and VA medical facilities’ program contracting officer’s representatives on the emergency and continuous supply provisions in the contracts, and ensure contracting officers’ representatives inform network and facility managers of the strategies offered by the prime vendors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to the receiving facilities during inter-facility transfers.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The Chief of Staff and Associate Director of Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2025

The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.1

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete required training.
Deficiencies in Disclosures and Quality Processes for Perforations Resulting from Urological Surgeries at West Palm Beach VA Medical Center in Florida
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21-01049-39
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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: 6/28/2022
The West Palm Beach VA Medical Center Director evaluates clinical disclosure practices and takes action as warranted to ensure compliance with Veterans Health Administration Directive 1004.08.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director ensures that Patient A’s and Patient B’s episodes of care are reviewed to determine if an institutional disclosure is needed per Veterans Health Administration Directive 1004.08 and takes action accordingly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director evaluates facility compliance with Veterans Health Administration Directive 1004.08 regarding institutional disclosure processes and takes corrective actions as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director explores reasons Joint Patient Safety Reports were not entered for some adverse events experienced by Patient A and Patient B and takes action accordingly to ensure compliance with Veterans Health Administration Handbook 1050.01.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director confirms that the Surgical Workgroup’s meeting minutes document oversight of the Surgical Service Morbidity and Mortality Conference by including issues discussed, conclusions, actions, recommendations, evaluations, and follow up in accordance with Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director identifies reasons a planned peer review was not completed in accordance with Veterans Health Administration Directive 1190 and takes corrective action as indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director reviews processes for evaluation of urologists’ privileging forms and takes action as necessary to ensure compliance with Veterans Health Administration Handbook 1100.19 and Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
VHA Improperly Paid and Reauthorized Non-VA Acupuncture and Chiropractic Services
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20-01099-249
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Topics:  Community Care ● Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2023
Ensure the Office of Community Care implements automated payment system controls to reject non VA claims that exceed the number of authorized visits or cutoff dates or includes treatment codes that deviate from established standards for care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2022
Ensure the Office of Community Care conducts ongoing payment system audits to identify and minimize improper payments of unauthorized claims.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the Health Information Management program office in coordination with the Office of Community Care and facility chiefs of staff to ensure facilities are conducting post payment audits of billed acupuncture and chiropractic services to verify non VA providers are properly supporting their claims and to develop processes for corrective actions based on audit results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2022
Ensure the Office of Community Care and the Health Information Management program office, in coordination with the offices of Acupuncture and Chiropractic services, make any current and future continuing education material related to documenting acupuncture and chiropractic services available to non VA providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2023
Direct facility chiefs of staff to require those authorized to approve non VA care to document review of prior care before approving additional services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2023
Instruct facility chiefs of staff to require VA providers to document their clinical justification for additional care requested by a veteran.
Total Monetary Impact of All Recommendations
Open: $ 341,700,000.00
Closed: $ 0.00
VHA Risks Overpaying Community Care Providers for Evaluation and Management Services
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21-01807-251
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Topics:  Community Care ● Financial Management

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the Health Information Management program office, in coordination with the Office of Community Care and facility chiefs of staff, to ensure facilities are conducting post payment audits of billed evaluation and management services to verify non VA providers are properly supporting their claims, including a focus on providers who frequently bill high level evaluation and management services and/or submit charges during periods when global surgery packages are in effect, and develop processes for corrective actions based on audit results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2022
Ensure the Office of Community Care and the Health Information Management program office make any current and future continuing education material related to documenting evaluation and management services available to non VA providers.
Total Monetary Impact of All Recommendations
Open: $ 59,600,000.00
Closed: $ 0.00
Comprehensive Healthcare Inspection Summary Report: Evaluation of Women's Health Care in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01508-32

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has processes and procedures in place for emergency care 24 hours per day, 7 days per week and facility call coverage for gynecologic care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a women veterans program manager who is full-time and free of collateral duties.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a designated maternity care coordinator.
Systems and Tools Implemented to Track COVID-19 Vaccine Data
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21-00913-267
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2022
The OIG recommended the under secretary for health develop processes for verifying facility data entered on the Pharmacy Benefits Management Services’ SharePoint website (or any subsequent data collection tool) for vaccine supply and usage.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health develop a process to monitor the use of tools that have been fielded to standardize data entry for vaccine doses administered by VA medical facilities and clinics to minimize data entry errors, including the Computerized Patient Record System’s clinical reminder, the Occupational Health Record-keeping System 2.0’s guided data entry guidance, and reports that can be used to identify data entry errors in these systems, or in any subsequent systems that VA uses to collect data on vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health make sure that the Power BI dashboard data are reliable, accurate, and complete, and capture all vaccine data more accurately for VA medical facilities in the same healthcare system.
VA Applications Lacked Federal Authorizations, and Interfaces Did Not Meet Security Requirements
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20-00426-02
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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: 6/17/2024

Review the SaaS applications named in the allegation to determine whether VA staff are still using them and whether such use is consistent with VA policy. If use is authorized, implement controls to ensure the applications go through the Federal Risk and Authorization Management Program authorization process and the VA SaaS application approval process. If use is not authorized, implement controls to prevent employees from using the SaaS applications without authority to operate.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/13/2022
Determine whether Federal Risk and Authorization Management Program authorization will be pursued for the IRBManager application. If the required federal authorization is not pursued, include this application in the annual certification letter to the Federal Chief Information Officer along with the appropriate rationale and proposed mitigation plan.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/13/2022
Implement JavaScript Object Notation Web Encryption for Lighthouse application programming interfaces that transmit sensitive information and resource-sharing requirements for cross-origin resource sharing to meet the requirements of VA Office of Information Security’s Application Programming Interface Security Pattern. Alternatively, coordinate with the Office of Information Security to determine if modifications or exceptions to security standards are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/13/2022
Implement alerts for application programming interface-related abuse to meet the requirements of the VA Office of Information Security’s Application Programming Interface Security Pattern.
Vet Center Inspection of Continental District 4 Zone 1 and Selected Vet Centers
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20-04050-37
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Topics:  Suicide Prevention
Related Media: Video

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director determines the reasons clinical and administrative quality review remediation plans do not include the Deputy District Director’s approval and date of approval as required and ensures compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director evaluates the clinical and administrative quality review process for resolution of quality review deficiencies and initiates action steps as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director evaluates the clinical and administrative quality review report process for determining timeliness in resolving quality review site visit deficiencies and initiates action steps as necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director determines the reasons critical incident quality reviews (currently known as mortality and morbidity review) for serious suicide attempts including analysis for corrective action were not completed, ensures completion, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director ensures the intake assessment portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director in collaboration with Readjustment Counseling Service Central Office evaluates the limitations of current tools and tracking methods including reasons completion dates are not visible in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director ensures clinical staff consult and coordinate care with the support Veterans Affairs medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with shared support Veterans Affairs medical facility for shared clients who are flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director ensures clinical staff consult with the vet center director, external clinical consultant or suicide prevention coordinator following a lethality status change as required and monitors compliance across all zone vet centers.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director in collaboration with the support Veterans Affairs medical facility clinical or administrative liaison determines the reasons for noncompliance with staff participation on mental health councils at the Casper, Denver, and Midland Vet Centers, and takes actions to ensure compliance with Readjustment Counseling Service requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director determines reasons an external clinical consultant was not assigned as required at the Midland Vet Center and ensures compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director determines reasons for noncompliance with processes for completing and tracking four hours per month of external clinical consultation at the Casper, Denver, El Paso, and Midland Vet Centers, and ensures that Vet Center Directors implement processes and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director determines reasons for noncompliance with staff supervision provided by the vet center directors at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that staff supervision occurs as required, and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director determines reasons for noncompliance with monthly RCSnet chart audits at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that chart audits are completed as required, and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2022
The District Director determines reasons for errors in training assignments for staff at the Casper, Denver, El Paso, and Midland Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director evaluates and determines reasons tactile (braille) signage was not posted at all exit doors at the Casper, Denver, El Paso, and Midland Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director reviews the reasons an updated emergency and crisis plan was not available at the Denver and Midland Vet Centers and ensures an updated plan is accessible to all staff.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director reviews reasons for noncompliance with client record storage at the Denver, El Paso, and Midland Vet Centers and ensures all client records are stored as required.
Discharge Planning Deficits for a Veteran at the Malcom Randall VA Medical Center in Gainesville, Florida
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21-01695-38
|
Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director reviews roles and responsibilities for interdisciplinary treatment team members and the process for communication of plans and recommendations from all clinical team members and takes action as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director ensures clinical staff follow established policy to alert clinical team of pertinent care changes by using the additional signer functionality or other methods of communication.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned occupational therapy provider involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the attending physician involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned social worker involved in the discharge planning for the patient and takes follow-up action as indicated.
Delayed Cancer Diagnosis of a Veteran Who Died at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico
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20-03700-35
|
Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2022
The Raymond G. Murphy VA Medical Center Director ensures supervising providers oversee all clinical decisions made by residents and the oversight is reflected within the documentation, including telephone notes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2024

The Raymond G. Murphy VA Medical Center Director ensures supervising providers establish a reliable way to receive alerts for the results of all tests ordered by residents.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that Primary Care and Specialty Care staff coordinate care for shared patients and evaluates the need for Outpatient Care Coordination Agreements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that patient, family, or staff concerns regarding delay in diagnosis are entered into the patient safety reporting system and appropriate follow-up is completed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director coordinates a comprehensive review of the patient’s care, takes action as warranted, and reconsiders an Institutional Disclosure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2023
The Raymond G. Murphy VA Medical Center Director ensures consistency between the relevant prior radiological images reviewed when staff radiologists and contract teleradiologists interpret imaging scans for Raymond G. Murphy VA Medical Center patients.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System in Bedford, Massachusetts
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21-00235-13
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2023
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain to designate a mental health professional to serve on each state’s suicide prevention council or workgroup.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2022
The Network Director determines the reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to required Veterans Integrated Service Network leaders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager conducts assessments to identify staff’s women’s health education gaps and develops or adapts educational programs, materials, or resources where gaps are identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager has Veterans Integrated Service Network-level support staff for data analysis and performance improvement projects.
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