All Reports

Failures in Care Coordination and Reviewing a Patient’s Death at the VA Salt Lake City Healthcare System in Utah
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21-00657-197
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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: 3/7/2022
The VA Salt Lake City Healthcare System Director conducts a clinical review of the care provided to the patient on Monday (day 7), by Idaho Falls Community-Based Outpatient Clinic staff, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director reviews the processes involved in conducting root cause analyses to ensure that final reports contain complete and accurate information.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director determines if an institutional disclosure is warranted following the completion of the clinical review of this patient’s care and takes action as necessary.
Comprehensive Healthcare Inspection of the VA Puget Sound Health Care System in Seattle, Washington
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20-01261-194
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Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines the reasons for noncompliance and ensures that improvement actions recommended by the Executive Leadership Council are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee completes at least eight patient safety analysis processes each fiscal year.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee includes an analysis of underlying systems in all root cause analyses.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that improvement actions identified from root cause analyses are implemented.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines reasons for noncompliance and ensures the Patient Safety Manager or designee provides an annual patient safety report to healthcare system leaders.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document focused professional practice evaluation criteria in practitioner profiles.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that licensed independent practitioners’ professional practice evaluations are completed by providers with similar training and privileges.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that service chiefs’ reprivileging decisions are based on ongoing professional practice evaluation data.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Credentialing and Privileging Committee meeting minutes consistently reflect the review of professional practice evaluation results and the rationale for privileging recommendations.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The System Director evaluates and determines any additional 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. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing for patients prior to initiating long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up evaluations of patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and effectiveness of the interventions.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete goals of care conversations and life-sustaining treatment decisions progress notes.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains the required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete competency assessments.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees receive monthly continuing education.
Contracted Residence Programs Need Stronger Monitoring to Ensure Veterans Experiencing Homelessness Receive Services
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19-08267-147
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Topics:  Clinical Care Services Operations

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Establish control mechanisms at the Veterans Integrated Service Network and Contracted Residential Services program levels to ensure Contracted Residential Services staff at medical facilities comply with Veterans Health Administration Handbook 1162.09 requirements for monitoring and documentation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
Direct Network Contracting Offices to establish controls to verify contracting officers meet with contracting officer’s representatives on at least a quarterly basis to evaluate contractor performance and document the meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/14/2022
Direct Network Contracting Offices for all Contracted Residential Services contracts to ensure contracting officers include quality assurance surveillance plans and promptly issue letters of delegation to staff who have been nominated to be contracting officer’s representatives.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Update Veterans Health Administration Handbook 1162.09 to incorporate unannounced site visits to the extent possible during annual inspections and quarterly evaluations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Update Veterans Health Administration Handbook 1162.09 to include guidance on paying for veteran absences and make certain these requirements are reflected in contracts and surveillance plans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 35,300,000.00
Audiology Leaders’ Deficiencies Responding to Poor Care and Monitoring Performance at the Eastern Oklahoma VA Health Care System in Muskogee
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20-04341-182
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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: 1/5/2022
The Eastern Oklahoma VA Health Care System Director confirms the Chief of Staff, the Service Chief, and the Supervisory Audiologist have processes in place to ensure patients affected by the audiologist’s poor care are identified and receive clinically-indicated follow-up.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s adverse event disclosure requirements, and takes action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2023
The Eastern Oklahoma VA Health Care System Director requires the Chief of Staff, the Service Chief, and the Supervisory Audiologist to complete clinical disclosures, as appropriate, for patients identified as being affected by the audiologist’s poor care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates the process to determine whether a large scale disclosure is required, in accordance with the Veterans Health Administration policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s patient safety reporting requirements, and takes action as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The Eastern Oklahoma VA Health Care System Director directs the Chief of Staff, the Service Chief, and the Supervisory Audiologist to notify the Patient Safety Manager of adverse events identified through the review of patients impacted by the audiologist’s poor care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures the Supervisory Audiologist verifies and documents annual competency assessments for audiologists in compliance with facility policy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures that the Supervisory Audiologist conducts performance appraisals of audiologists in compliance with the Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with Veterans Health Administration’s state licensing board reporting policy, and takes action as indicated.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates a review of the audiologist’s conduct to determine whether a report to the state licensing board is indicated, in accordance with the Veterans Health Administration policy.
VBA’s Fiduciary Program Needs to Improve the Timeliness of Determinations and Reimbursements of Misused Funds
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20-00433-168
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Topics:  Claims and Fiduciary
Related Media: Video

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/21/2021
The OIG recommended the under secretary for benefits implement a mechanism for ensuring negligence determinations subsequent to December 31, 2017, are completed promptly and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/6/2022
The OIG recommended the under secretary for benefits implement a mechanism for ensuring reimbursements subsequent to December 31, 2017, are completed promptly and monitor compliance.
Deficiencies in the Mental Health Care of a Patient who Died by Suicide and Failure to Complete an Institutional Disclosure, VA Southern Nevada Healthcare System in Las Vegas
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20-02993-181
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Topics:  Mental Health ● Suicide Prevention ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures completion of suicide risk screening and evaluation in accordance with Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff collaboratively develop and update safety plans with patients to reflect the patient’s current risk and protective factors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures adherence to Veterans Health Administration requirements and VA Southern Nevada Healthcare System Standard Operating Procedure 116-14, Suicide Prevention Daily Operations, October 2019, in the consideration of high risk for suicide patient record flags.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director evaluates substance use disorder diagnostic and treatment referral processes for patients on the Inpatient Mental Health Unit and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director reviews current practices to ensure Inpatient Mental Health Unit staff reconcile and incorporate critical clinical information into treatment and discharge planning.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director expedites the establishment of mental health treatment coordinator policy in accordance with Veterans Health Administration requirements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff coordinate discharge plans with outpatient treatment providers, in accordance with Veterans Health Administration requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director ensures patient complaints and requests are addressed in accordance with Veterans Health Administration requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The VA Southern Nevada Healthcare System Director promotes leaders’ accurate identification of sentinel events consistent with The Joint Commission definition and Veterans Health Administration requirements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The VA Southern Nevada Healthcare System Director conducts a full review of the patient’s care, determines whether an institutional disclosure is warranted, and takes action as indicated.
Adaptive Sports Grants Management Needs Improvement
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20-01807-173
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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: 3/17/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop standard operating procedures for all processes related to managing the adaptive sports grants program.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop and train current staff and identify and hire staff specialized in grants management.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish and execute a plan to evaluate risks posed by grant applicants before awarding grants, in accordance with VA financial policy.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish procedures to ensure the timely reimbursement of grant recipient expenses.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish grant closeout procedures that include communicating timelines with the grant recipients, documentation requirements for proper grant closeout, availability of grant funds, and a process to approve modification and extension requests.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director act to ensure all adaptive sports grants are closed out on time.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2024

The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director determine, in coordination with VA’s Office of Finance and Office of General Counsel, whether a Purpose Statute violation occurred, whether account adjustments need to be made, whether Antideficiency Act violations occurred, and report any Purpose Statute and Antideficiency Act violations.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 247,000.00
Comprehensive Healthcare Inspection of the VA Portland Health Care System in Oregon
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20-01257-180
|
Topics:  Patient Safety ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety and Value Council’s recommended improvement actions are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Utilization Management Committee’s recommended improvement actions are fully implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures all root cause analysis actions are fully implemented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional 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: 1/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of aberrant drug-related behaviors prior to initiating long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing as recommended for patients on long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct follow-up assessments that include adherence to the pain management plan of care and effectiveness of the interventions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete life-sustaining treatment decisions progress notes prior to hospice referrals.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Women Veterans Health Committee meetings.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures standard operating procedures are kept up-to-date and reviewed at least every three years.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Endoscopy Clinic clean storage room maintains the required relative humidity range.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho
|
20-01256-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain a licensed healthcare professional’s first- or second-line supervisor completes provider exit review forms within seven business days of professionals’ departure from the medical center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five suicide prevention outreach activities per month.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all staff complete annual suicide prevention refresher training. 
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners complete life-sustaining treatment decision progress notes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that processes and procedures are in place for 24 hours a day, 7 days per week Emergency Department and medical center call coverage for gynecologic care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Medical Center 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 or arrangements for leave coverage when there is only one designated provider.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that align with medical center standard operating procedures prior to reprocessing reusable medical equipment.
Deficiencies in the Completion of Community Care Consults and Leaders’ Oversight at the New Mexico VA Health Care System in Albuquerque
|
20-00716-177
|
Topics:  Community Care ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director verifies monitoring is in place to ensure that clinical documentation is obtained from non-VA providers, scanned into the electronic health record, and attached to the applicable consult prior to completion of the consult.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2021
The New Mexico VA Health Care System Director evaluates program effectiveness and monitors the Chief of Community Care’s implementation of the competency and training program for Community Care Service nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director confirms the Consult and Access Management Steering Committee updates its charter and oversees all aspects of the consult process as required by the Veterans Health Administration consult management policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director determines that staff responsible for monitoring and oversight, as identified by the Chief of Staff and the Consult and Access Management Steering Committee, develop and implement a process to evaluate Community Care consult processes and procedures for consistency with Veterans Health Administration policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director reviews the organizational structure of the facility’s Community Care Department, including available positions, evaluates the expertise of leaders and supervisory staff to ensure effective management and oversight, and takes action as necessary.
VBA Overpaid Veterans Due to Delays in Reducing Compensation Benefits
|
20-03229-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Establish, document, and implement a workload management strategy to distribute and process proposals to reduce benefits that minimizes delays and excessive payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Develop, document, and implement a formal procedure to routinely monitor the workload management strategy to ensure it minimizes delays and excessive payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 348,000,000.00
Training Deficiencies with VA’s New Electronic Health Record System at the Mann-Grandstaff VA Medical Center in Spokane, Washington
|
20-01930-183
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Topics:  Electronic Health Records Modernization (EHRM)

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: 1/23/2023
The Under Secretary for Health explores the establishment of a group of Veterans Health Administration staff comprised of core user roles with expertise in Veterans Health Administration operations and Cerner electronic health record use with data architect level knowledge to lead the effort of generating optimized Veterans Health Administration clinical and administrative workflows.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary establishes an electronic health record training domain that ensures close proximation to the production environment and is readily available to all end users during and following training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary ensures end users receive training time sufficient to impart the skills necessary to use the new electronic health record prior to implementation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary ensures the user role assignment process addresses identified facility leaders and staff concerns.
No. 5
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary ensures Cerner trainers and adoption coaches have the capability to deliver end user training on Cerner and Veterans Health Administration electronic health record software workflows.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/1/2022
The Deputy Secretary evaluates the process of super user selection and takes action as indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary reviews the Office of Electronic Health Records Modernization’s performance-based service assessments for Cerner’s execution of training to determine whether multiple, recurrent concerns are being accurately captured and addressed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary oversees the revision of an Office of Electronic Health Records Modernization training evaluation plan and ensures implementation of stated objectives.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/1/2022
The Deputy Secretary reviews the Electronic Health Record Modernization governance structure and takes action as indicated to ensure the Under Secretary for Health’s role in directing and prioritizing Electronic Health Record Modernization efforts is commensurate with the Veteran Health Administration’s role in providing safe patient care.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2022
The Under Secretary for Health establishes guidelines and training to capture new electronic health record-related patient complaints, including patient advocacy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The Under Secretary for Health ensures an assessment of employee morale following implementation of a new electronic health record and takes action as indicated.
Inadequate Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations
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20-03704-165
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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: 6/16/2022
Establish procedures at all facilities with affiliated nonprofit corporations to help ensure VA medical center Research and Development Budget Office staff review nonprofit corporation invoice documentation and confirm services were performed before approving payment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
Establish procedures for Research and Development Budget Office supervisors at all the VA medical centers with affiliated nonprofit corporations that ensure periodic reviews are conducted of invoices authorized for payment, confirming that staff verified services were performed before approving payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2022
Ensure the Nonprofit Program Office invoice review procedures incorporate verification that affiliated nonprofit corporations include evidence that services were provided with invoices submitted to VA.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,900,000.00
Unreliable Information Technology Infrastructure Cost Estimates for the Electronic Health Record Modernization Program
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20-03185-151
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 11/9/2022

Ensure an independent cost estimate is performed for program life-cycle cost estimates related to information technology infrastructure costs.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Reassess the cost estimate for Electronic Health Record Modernization program-related information technology infrastructure and refine as needed to comply with VA’s cost-estimating standards. 

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Develop procedures for cost-estimating staff that align with VA cost-estimating guidance.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure costs for all information technology infrastructure upgrades funded by the Office of Information and Technology and the Veterans Health Administration or other sources needed to support the Electronic

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Formalize agreements with the Office of Information and Technology and the Veterans Health Administration identifying the expected contributions from each entity toward information technology infrastructure upgrades in support of the Electronic Health Record Modernization program.

No. 6
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Establish procedures that identify when life-cycle cost estimates should be updated and ensure those updated estimates are disclosed in the program’s congressionally mandated reports.

Comprehensive Healthcare Inspection of Veterans Integrated Service Network 10: VA Healthcare System Serving Ohio, Indiana and Michigan in Cincinnati
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20-01265-172
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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: 7/1/2021
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the credentials files of physicians who had a potentially disqualifying licensure action are reviewed with Regional Counsel, or a designee, and submitted for approval of VA appointment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2021
The Network Director evaluates and determines any additional reasons for noncompliance and appoints a Veterans Integrated Service Network lead women veterans program manager.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead women veterans program manager provides quarterly program updates to executive leaders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead women veterans program manager completes annual site visits at each facility within the Veterans Integrated Service Network.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2021
The Network Director determines the reasons for noncompliance and makes certain that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2022
The Network Director determines the 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.
VHA Made Inaccurate Payments to Part-Time Physicians on Adjustable Work Schedules
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20-01646-139
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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: 2/26/2025

Ensure payroll personnel complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2025

Establish oversight procedures to make certain that part-time physicians submit and validate their subsidiary time sheets and that supervisors promptly certify the time sheets.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2024

Train newly assigned payroll personnel on agreement reconciliation procedures and develop follow-up procedures to prevent missed reconciliations because of staff turnover.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

Implement procedures to confirm service chiefs conduct quarterly reviews of all adjustable work hour agreements that include identifying physicians with significant variances from the agreements or indicators that the cap on part-time hours is likely to be exceeded and taking corrective actions.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

Document oversight procedures for monitoring and validating compliance with the requirements of the part-time physician on adjustable work schedules program.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2025

Direct the program office, in coordination with the VA Office of General Counsel, to determine whether medical centers committed Antideficiency Act violations by not correcting underpayments and preventing physicians from working above the annual limit of 1,820 hours.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2025

Establish oversight procedures for monitoring and validating their medical centers’ compliance with the requirements of the part-time physician on adjustable work schedules program.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/8/2022
Complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/8/2022
Document oversight procedures for monitoring and validating that all reconciliations and payment corrections are completed when agreements expire or are terminated.
Total Monetary Impact of All Recommendations
Open: $ 16,600,000.00
Closed: $ 0.00
Failure of a Primary Care Provider to Complete Electronic Health Record Documentation and Inadequate Oversight at the Charlie Norwood VA Medical Center in Augusta, Georgia
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20-00354-178
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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: 12/14/2021
The Charlie Norwood VA Medical Center Director confirms that the Chief of the Health Information Management program monitors documentation to include patient care episodes without an associated progress note as part of the ongoing electronic health record review process, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The Charlie Norwood VA Medical Center Director ensures a policy defines the required time frame for providers to respond to view alerts.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2021
The Charlie Norwood VA Medical Center Director continues to monitor providers’ compliance with responding to view alerts, evaluates the effectiveness of the implemented strategies to reduce unnecessary view alerts, and assesses the need for retrospective reviews of patient care related to accumulated view alerts.
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