All Reports

Deficiencies in the Assessment and Care of a Patient Seeking Geriatric Services at the Fayetteville VA Medical Center in North Carolina
|
21-00371-222
|
Topics:  Patient Safety ● Care Coordination

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that community health nurses evaluate patients referred for homemaker and/or home health aide services in accordance with Veterans Health Administration policy when determining patient eligibility.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2023
The Fayetteville VA Medical Center Director verifies that interdisciplinary assessments of homemaker and/or home health aide referrals are completed to determine patient eligibility for services.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Fayetteville VA Medical Center Director ensures that community health staff are trained on the eligibility criteria for homemaker and/or home health aide services.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2022
The Fayetteville VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of North Carolina commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures that providers consistently assess and document when patients lack decision-making capacity.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Fayetteville VA Medical Center Director ensures thatproviders consistently determine whether a patient has an identified healthcare agent when patients lack decision-making capacity.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Fayetteville VA Medical Center Director makes certain that patient aligned care team providers and outpatient psychiatrists are educated about initiating specialty care consults for patients.
Deficiencies in Coordination of Care for Patients with Treatment-Resistant Depression at the VA San Diego Healthcare System in California
|
20-03359-220
|
Topics:  Mental Health ● Community Care ● Care Coordination

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Under Secretary for Health requires that all community care providers authorized to provide ketamine or esketamine for treatment-resistant depression receive and review VA’s National Protocol Guidance on ketamine infusion and intranasal esketamine.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/25/2022
The Under Secretary for Health evaluates the need for conducting research on the use of ketamine and esketamine for treatment-resistant depression including the comparative efficacy of ketamine and esketamine, the effect of route of administration, therapeutic dose range, mechanism of action, and efficacy and safety of long-term treatment, and initiates research efforts as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director confirms that the facility’s Community Care Service takes timely actions to ensure that administrative processes for care authorization do not disrupt continuity of clinical care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director makes certain that the facility’s Community Care Service processes incorporate relevant clinical service input in decisions regarding authorization, denial, or discontinuation of care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The VA San Diego Healthcare System Director ensures that the facility’s Community Care Service processes incorporate a consistent mechanism for communication with Veterans Health Administration and community clinical providers and patients to facilitate well-timed coordination of care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The VA San Diego Healthcare System Director monitors implementation of the coordinated, clinically informed plans for continuing care when transitioning the remaining patients from ketamine treatment in the community to care at the facility.
Comprehensive Healthcare Inspection of the Montana VA Health Care System in Fort Harrison
|
21-00232-205
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator reports directly to the Director or one supervisory level below the Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and core members consistently attend meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group reviews surgical deaths and National Surgery Office surgical quality reports, analyzes efficiency and utilization metrics, and recommends appropriate actions to the System Director.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that specific action items are implemented and monitored when problems or opportunities for improvement are identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The System 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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory training prior to developing suicide safety plans.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2021
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The System 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 areas.
Review of Veterans Health Administration Staffing Models
|
20-01508-214
|
Topics:  Staffing

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health coordinates with VA to review the roles, responsibilities, and number of staff required for the VA and Veterans Health Administration offices involved in the development, validation, and implementation of staffing models, and ensure that staffing model-related efforts are prioritized and supported.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2025

The Under Secretary for Health coordinates with VA to evaluate the status of, and provide a timeline for, the development, validation, and implementation of Veterans Health Administration staffing models for all occupations.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2025

The Under Secretary for Health coordinates with VA to evaluate the status of, and provide a timeline for, the implementation of HR Smart-related requirements referenced in VA and Veterans Health Administration policy, with a specific focus on the authorizations, vacancies, budgeted positions, and unbudgeted requirements at the facility, Veterans Integrated Service Network, and national levels.

Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas
|
20-03635-217
|
Topics:  COVID-19 ● Mental Health ● Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.
Comprehensive Healthcare Inspection of the VA Western Colorado Health Care System in Grand Junction
|
21-00247-210

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2021
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board reviews aggregated quality, safety, and value data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2021
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board’s recommended improvement actions are fully implemented and monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Executive 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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Ineffective Governance of Prescription Drug Return Program Creates Risk of Diversion and Limits Value to VA
|
20-00418-166
|
Topics:  Supplies and Equipment

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel secure prescription drugs set aside for return credit either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel account for all prescription drugs set aside for return credit when they leave the medical facility either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel maintain inventory management practices to make sure drugs that are returned for credit are returned in a timely manner, so that medical facilities do not miss opportunities to maximize the value of their drug returns or reduce their risk of overspending to replace drugs prematurely returned for credit.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2022
The OIG recommends that the under secretary for health takes steps to provide all offices and positions with defined national, network, or facility responsibilities for the drug return program or the administration of any future drug return contract(s), to include Pharmacy Benefits Management Services, Veterans Integrated Service Network pharmacist executives, network contracting officers, contracting officer representatives, and medical facility pharmacy chiefs, with the support, such as training, and the authority needed to carry out those responsibilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2022
The OIG recommends that the under secretary for health makes sure that Pharmacy Benefits Management Services reviews the drug return contractor(s) data for accuracy, and uses this data to identify unusual reimbursement patterns and potential improvements for revenue recovery through the last invoices issued as part of the October 2018 Pharma Logistics contract, and for any future drug return contract(s); and coordinate with the National Contract Service on corrective action if inaccurate contractor data is identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health implements mechanisms to make sure that contracting officer representatives, if assigned, or Veterans Health Administration network contracting officers, provide oversight to ensure the contractor is performing in accordance with the terms of any future drug return contract(s).
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health, to minimize the risk of errors, makes sure that Veterans Health Administration network contracting officers when writing task orders off any future drug return contract(s) use a template with terms that align with any future drug return contract(s) developed by the National Contract Service.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health coordinate with the VA Office of Acquisition, Logistics, and Construction’s principal executive director, who should develop a task order template with terms that align with any future drug return contract(s) and require the National Contract Service to disseminate the template to Veterans Health Administration network contracting officers.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,907,365.00
Financial Efficiency Review of the Miami VA Healthcare System
|
20-01796-195
|
Topics:  Financial Management

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System develop a plan to work with the assigned prime vendor to address having adequate stock from the facility’s formulary list in its warehouse to provide supplies when ordered.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System ensure logistics staff use the tools available to inform the Medical Supplies Program Office of prime vendor performance issues.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The OIG recommended the director of the Miami VA Healthcare System establish controls to confirm approving officials and purchase cardholders review their proposed purchases and make sure contracting is used when it is in the best interest of the government.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System 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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The OIG recommended the director of the Miami VA Healthcare System develop measures to confirm completed VA Form 0242 submissions are accurate and updated for all cardholders
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System provide guidance on implementing the healthcare system policy “Resource Management Board,” including measurable objectives or clear criteria to determine if a service line is efficiently managing administrative staffing.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System establish controls to make certain that budget or accounting staff review the salary cost data each pay period and promptly address cost center corrections with human resources staff as needed.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System ensure service chiefs and supervisors review labor mapping for accuracy and completeness.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System continue to develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System establish measures to improve compliance with the VA directive to avoid end of year pharmaceutical purchases.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 328,000.00
Comprehensive Healthcare Inspection of the Sheridan VA Medical Center in Wyoming
|
21-00255-200
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
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: 7/7/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
Improvements Still Needed in Processing Military Sexual Trauma Claims
|
20-00041-163
|
Topics:  Military Sexual Trauma

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/22/2022
Establish and implement a formal procedure to ensure all processing errors on claims identified by the review team are corrected and report the results to the OIG.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 4/30/2025

Develop, implement, and monitor a written plan to address continuing military sexual trauma claims processing deficiencies identified by the review team, including reassessing previously decided claims when appropriate, and report the results to the OIG.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2023
Strengthen controls to effectively implement and promote compliance with 2018 OIG report recommendations related to military sexual trauma claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2023
Develop, implement, and monitor a written plan that requires the Compensation Service and the Office of Field Operations to strengthen communication, oversight, and accountability of military sexual trauma claims processing.
Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations
|
20-01979-199
|
Topics:  Military Sexual Trauma

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2022
The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding protected administrative time, administrative staff support, and funding for outreach, education, and special project resources, with consideration of the Military Sexual Trauma Coordinators’ responsibilities, and takes action as warranted.
Comprehensive Healthcare Inspection of the Mann-Grandstaff VA Medical Center in Spokane, Washington
|
20-01262-191
|
Topics:  Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Medical Center Director determines reasons for noncompliance and ensures that the Protected Peer Review Committee completes final reviews within 120 calendar days or has a written extension request approved by the Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/30/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses’ corresponding actions and outcome measures show sustained improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in practitioners’ profiles.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff determines the reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic, with the veterans’ preference documented, within the required time frame.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete suicide safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five outreach activities each month.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual refresher training.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that written processes and procedures are in place for 24 hours per day, 7 days per week gynecological care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned to and consistently attend Women Veterans Health Committee meetings.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Medical Center Director evaluates and determines the reasons for noncompliance and makes certain the Women Veterans Program Manager collects and tracks data for follow-up of abnormal mammogram and cervical cytology reports and the timeliness of breast and cervical cancer treatment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment complete competency assessments.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 20: VA Northwest Health Network in Vancouver, Washington
|
20-01254-185
|
Topics:  Medical Staff Privileging Credentialing

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2022
The Chief Medical Officer determines the 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: 1/10/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead oversees facility development of corrective action plans within the required time frame and tracks action items until closure.
Opportunities Exist to Improve Management of Noninstitutional Care through the Veteran-Directed Care Program
|
20-02828-174
|
Topics:  Patient Care Services Operations

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2023
The OIG recommended the under secretary for health establish a process to ensure program personnel document veterans’ quarterly monitoring in their electronic health records, such as by using a standardized template.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The OIG recommended the under secretary for health etablish a process to ensure the provider agency list in the Electronic Claims Adjudication Management System is updated as new provider agencies are added to the program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The OIG recommended the under secretary for health etablish a process to ensure proper pricing in the Electronic Claims Adjudication Management System when paying program claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The OIG recommended the under secretary for health update program guidance on claims submission and processing to make sure provider agencies are aware of the need to include all required information when submitting program claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2023
The OIG recommended the under secretary for health establish guidance to include processes that medical facilities must follow to determine if veterans are receiving the same personal care services through the Veteran Directed Care program and the Program of Comprehensive Assistance for Family Caregivers, and how to address these situations, as appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The OIG recommended the under secretary for health ensure program personnel determine if veterans enrolled in both the Veteran Directed Care and the Program of Comprehensive Assistance for Family Caregivers are receiving the same personal care services and take action, as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024

The OIG recommended the under secretary for health establish procedures to identify program staffing needs and define program personnel’s roles and responsibilities at the national, network, and local levels.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The OIG recommended the under secretary for health update procedures for tracking and reporting demand for and use of program services and use these data to inform yearly cost estimates for the program.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,570,395.00
Deficiencies in Mental Health Care Coordination and Administrative Processes for a Patient Who Died by Suicide, Ralph H. Johnson VA Medical Center, Charleston, South Carolina
|
20-02368-202
|
Topics:  Mental Health ● Care Coordination ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Ralph H. Johnson VA Medical Center Director ensures adherence to Veterans Health Administration policy in the renewal review of patients’ high risk for suicide patient record flag, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director evaluates compliance with Mental Health Treatment Coordinator assignment requirements, and takes action to address identified deficiencies as indicated.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director reviews the patient’s care to include staff’s adherence to “Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment” program requirements and appropriate outreach, consults with Human Resources and General Counsel Offices, and takes action as warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Ralph H. Johnson VA Medical Center Director ensures that Mental Health Service staff complete patients’ suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director evaluates procedures for non-clinical staff to notify appropriate leaders of patient deaths by suicide, and takes action as needed.
Deficiencies in the Management of a Patient’s Reported Intimate Partner Violence, Ralph H. Johnson VA Medical Center, Charleston, South Carolina
|
20-03763-207
|
Topics:  Mental Health ● Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director ensures mental health staff consult with the Intimate Partner Violence Assistance Program and safety plan, as warranted to address Intimate Partner Violence.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Ralph H. Johnson VA Medical Center Director ensures Inpatient Mental Health Unit resident physicians complete timely clinical documentation in accordance with Ralph H. Johnson VA Medical Center Policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director makes certain staff consult with the Office of General Counsel to determine reporting requirements of Intimate Partner Violence, as appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The Under Secretary for Health establishes clear guidance related to Intimate Partner Violence training requirements.
Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon
|
20-01259-196
|
Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager or designee includes all required review elements in root cause analyses.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs evaluate practitioners based on service-specific criteria.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines the reasons for noncompliance and makes certain the Executive Council of Medical Staff reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
The System Director evaluates and determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Suicide Prevention Coordinator provides in-person Operation S.A.V.E. training at new employee orientation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations within the required time frame.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures are reviewed at least every three years and updated when there is a change in process or manufacturer’s instructions for use.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures that all employees who reprocess reusable medical equipment receive monthly continuing education.
Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2020
|
21-00519-192
|
Topics:  Financial Management

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2022
The OIG recommended the under secretary for benefits ensure the Pension Program meets its reduction target.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The OIG recommended the under secretary for health ensure the Purchased Long-Term Services and Supports Program meets its reduction target.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/13/2023

The OIG recommended the under secretary for health reduce improper payments to below 10 percent for Beneficiary Travel; Communications, Utilities, and Other Rent; Medical Care Contracts and Agreements; Purchased Long Term Services and Supports; and VA Community Care Programs and activities.

Displaying 721 - 740 of 4252