All Reports

Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01507-61
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Topics:  Patient Safety ● Mental Health

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers complete aberrant behavior risk assessments on all patients prior to initiating long-term opioid therapy.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.

No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers communicate problematic urine test results to patients.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers follow up with patients within three months after initiating opioid therapy to assess adherence to the pain management plan of care and effectiveness of interventions.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2024

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities monitor the quality of pain assessment and effectiveness of pain management interventions.

Audit of Community Care Consults during COVID-19
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21-00497-46
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Topics:  COVID-19 ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2023
Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2023
Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.
VA’s Use of the Defense Logistics Agency’s Electronic Catalog for Medical Items
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20-00552-30
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Topics:  Financial Management ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2022
Update the Electronic Catalog Ordering Guide with additional guidance to clarify the requirement to consider Federal Supply Schedule contracts before ordering medical supplies and equipment through the Defense Logistics Agency’s Electronic Catalog and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
Establish a process to monitor orders through the Defense Logistics Agency’s Electronic Catalog to identify recurring acquisitions that could be purchased through other contract vehicles at a lower price.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
Require a justification for every order through the Defense Logistics Agency’s Electronic Catalog if a Federal Supply Schedule contract is available.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2024

Correct and monitor compliance with the Rule of Two diagram in the Electronic Catalog Ordering Guide.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2024

Establish a process to ensure appropriate documentation and audits of orders in accordance with the Electronic Catalog Ordering Guide.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/31/2023
Conduct and document annual reviews as required in the interagency agreement.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,420,878.00
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 8: VA Sunshine Healthcare Network in St. Petersburg, Florida
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21-00236-44
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2022
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials files and approve the VA appointments of physicians who had potentially disqualifying licensure actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the Lead Women Veterans Program Manager completes yearly site visits at each facility within the Veterans Integrated Service Network.
Comprehensive Healthcare Inspection of the Charles George VA Medical Center in Asheville, North Carolina
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21-00279-54
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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: 8/24/2022
The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure all patient transfers are monitored and evaluated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that referring providers complete all required elements of the VA Inter-facility Transfer Form or facility-defined equivalent prior to patient transfers.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2023
The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2022
The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/14/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that Employee Threat Assessment Team members complete the required training.
MISSION Act Market Assessments Contain Inaccurate Specialty Care Workload Data
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20-03351-08

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

The OIG recommended that the acting under secretary for health perform additional analyses to ensure materially accurate specialty care workload data are used to implement the Asset and Infrastructure Review Commission recommendations.

Vet Center Inspection of Pacific District 5 Zone 2 and Selected Vet Centers
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21-01804-56
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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: 5/12/2022
The District Director determines reasons for missing and incomplete clinical quality reviews, remediation plans, and resolution of deficiencies; ensures completion; and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The District Director evaluates the process for resolution of clinical quality review deficiencies and initiates action as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The District Director determines reasons for missing and incomplete administrative quality reviews, remediation plans, and resolution of deficiencies; ensures completion; and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2024

The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2022
The District Director ensures intake assessments are completed and monitors compliance across all zone vet centers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/9/2024

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

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
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 and lethality risk assessments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The District Director ensures clinical staff consult and coordinate care with the shared support VA medical facility for clients with high risk for suicide flag placement and monitors compliance across all zone vet centers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/9/2022
The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at 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: 11/9/2022
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: 8/9/2022
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: 5/12/2022
The District Director, in collaboration with the support VA medical facility clinical or administrative liaison, determines the reasons for noncompliance with staff participation on mental health councils at the Fresno, High Desert, Honolulu and Santa Cruz County Vet Centers, and takes action as required.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The District Director determines reasons for noncompliance with completing and tracking the required four hours of external clinical consultation per month, ensures that Vet Center Directors have processes to track consultation hours, and monitors compliance at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The District Director determines reasons for noncompliance with staff supervision provided by the Vet Center Directors at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2023
The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures chart audits are completed as required, and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2023
The District Director determines reasons why trainings were not completed at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the High Desert, Honolulu, and Santa Cruz County Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards requirements.
Financial Efficiency Review of the Marion VA Medical Center in Illinois
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21-00960-17
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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: 7/12/2022
Develop a plan to routinely provide updates when changes in stock levels are anticipated and work with the prime vendor to address having adequate stock to meet orders.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
Ensure logistics staff and 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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2022
Implement a process to routinely check the formulary for additions and update the ordering system to reflect the prime vendor as the source for purchasing newly added supplies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
Ensure healthcare system finance office staff are made aware of policy requirements and the responsible finance office conducts reviews on all open obligations as required by VA Financial Policies and Procedures, vol. II, chap. 5, “Obligations Policy,” January 2018.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
Promote veterans’ use of the Consolidated Mail Outpatient Pharmacy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
Educate non-VA providers on prescribing lower-cost drugs.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
Implement Veterans Integrated Service Network 15 recommendations to ensure the cost-saving initiatives are implemented, tracked, and monitored to achieve identified efficiency targets and use available pharmacy data to make business decisions.
Deficiencies in a Patient’s Lung Cancer Screening, Renal Nodule Follow-Up, and Prostate Cancer Surveillance at the VA Southern Nevada Healthcare System in Las Vegas
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21-01038-49
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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: 12/7/2022
The VA Southern Nevada Healthcare System Medical Center Director reviews primary care and pulmonology processes to ensure patients with high-risk factors for lung cancer receive screening and follow-up care and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
The VA Southern Nevada Healthcare System Medical Center Director implements processes to ensure that patients with abnormal radiology findings have appropriate follow-up and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
The VA Southern Nevada Healthcare System Medical Center Director ensures that providers follow the guidelines for surveillance for patients who have undergone prostatectomy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA Southern Nevada Healthcare System Medical Director reviews primary care providers’ copy and paste practices, implements processes to ensure a current plan of care is documented in the electronic health record, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA Southern Nevada Healthcare System Medical Center Director reviews the complaint reporting and responding processes, ensures complaints are addressed in accordance with Veterans Health Administration policy, and monitors compliance.
Inadequate Oversight of VHA’s Home Oxygen Program
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19-07812-29
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Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The OIG recommended that the under secretary for health implement comprehensive guidance for staff who schedule home oxygen consults that includes processes for working with patients who do not or are unable to attend scheduled reevaluations, and for determining how and when to discontinue home oxygen services when appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The OIG recommended that the under secretary for health update guidance to include any exceptions to the scheduling time frame based on the type of home oxygen services patients are prescribed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2023
The OIG recommended that the under secretary for health update policy to assign oversight responsibility for ensuring the number of home or telehealth visits outlined in guidance is conducted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2023
The OIG recommended that the under secretary for health require the network contracting offices to provide oversight so that (1) contracting officers ensure vendor performance evaluations and quality assurance reports are completed and documented in the electronic contract management system, and (2) contracting officers comply with requirements when designating contracting officer’s representatives.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2023
The OIG recommended that the under secretary for health clearly communicate processes or tools that staff should use to achieve the contract monitoring requirements outlined in the Federal Acquisition Regulation.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/4/2022
The OIG recommended that the under secretary for health ensure facilities in Veterans Integrated Service Network 7 review orders that were paid for home oxygen services without an awarded contract and submit a request for ratification to the head of the contracting activity for any unauthorized commitments.
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
|
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
|
21-00277-41
|
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
|
21-01049-39
|
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
|
20-01099-249
|
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
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