Date Issued
|
Report Number
21-00669-176
All Reports
Date Issued
|
Report Number
20-00345-77
|
Topics: Contract Integrity
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers obtain and maintain evidence of contractor-provided lists of all personal identity verification cards issued to contractor employees.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers maintain evidence documenting personal identity verification cards were returned to the issuing or designated office when the cards were no longer required and prior to closing the contract.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to evaluate the role of contracting officer’s representatives in the personal identity verification card process for contractor employees and assess whether updates to their letter of delegation and standard operating procedures are necessary.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish policies and procedures outlining specific supervisory responsibilities for contracting officer oversight in accordance with the Government Accountability Office Standards for Internal Controls in the Federal Government.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess the contract completion statement template to determine whether to include the contractor-related personal identity verification card requirements.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures within the Procurement Audit Office for periodic reviews of contract files to determine compliance with the personal identity verification card requirements established in the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, require the results of these reviews to be reported to senior management to help determine whether corrective actions are required.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to determine whether existing or planned systems can have the functionality to allow management to effectively and routinely monitor contractor employee personal identity verification cards or whether a new system should be established.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/26/2026
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess whether contracting officers should be required to include the contractor-provided list as an explicit requirement in all Veterans Health Administration contracts that require issuance of personal identity verification cards to contractor employees.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures to ensure contracting officers include Federal Acquisition Regulation clause 52.204-9, “Personal Identity Verification of Contractor Personnel,” in contracts when required.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to consider directing contracting officers to delay final payment to contractors on future contracts until all personal identity verification cards have been returned.
Date Issued
|
Report Number
19-09808-171
|
Topics: Mental Health
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/2/2022
The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
Date Issued
|
Report Number
20-00176-125
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs develop controls to ensure state grants are prioritized and awarded in accordance with the Code of Federal Regulations.
No. 2
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs develop and implement written policies and procedures for grant prioritization.
No. 3
to National Cemetery Administration (NCA)
Closure Date: 11/15/2022
The OIG recommended the under secretary for memorial affairs evaluate all current national headstone and niche cover contracts for appropriate penalties and clauses for timeliness and quality issues and enforce and amend those contracts as necessary.
No. 4
to National Cemetery Administration (NCA)
Closure Date: 5/11/2022
The OIG recommended the under secretary for memorial affairs direct the Improvement and Compliance Service to assign levels of importance to standards and measures used for compliance reviews and test the inscription accuracy of all gravesites sampled.
No. 5
to National Cemetery Administration (NCA)
Closure Date: 2/7/2024
The OIG recommended the under secretary for memorial affairs require all state and tribal cemeteries to submit certified condition and operations performance assessments annually.
No. 6
to National Cemetery Administration (NCA)
Closure Date: 5/11/2022
The OIG recommended the under secretary for memorial affairs ensure representatives from all state and tribal cemeteries are provided opportunities to participate in National Cemetery Administration standards training via remote training options and monitor all training to ensure adequate participation.
No. 7
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs continue to seek an increase in cemetery grant funding in excess of $45 million
No. 8
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs ensure that the Improvement and Compliance Service follows up with Hawaiian cemeteries after action plans are submitted to ensure deficiencies are corrected.
No. 9
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs implement controls to ensure cemeteries that receive provisionally compliant or noncompliant scores during reviews are followed up with on a fixed and regular basis until sufficient corrective action plans are submitted.
No. 10
to National Cemetery Administration (NCA)
Closure Date: 3/4/2024
The OIG recommended the under secretary for memorial affairs use accountability measures in the Code of Federal Regulations when appropriate if grantees do not take adequate steps to correct significant long standing deficiencies.
No. 11
to National Cemetery Administration (NCA)
Closure Date: 8/16/2023
The OIG recommended the under secretary for memorial affairs work with the State of Hawaii Office of Veterans’ Services to conduct an extensive assessment of all eight Hawaii state veterans cemeteries, including organizational oversight and operations, staffing needs (including training), gravesite marker accuracy, and grounds conditions.
Date Issued
|
Report Number
20-01273-162
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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 that a first- or second-line supervisor completes a provider exit review form within seven business days of a licensed independent practitioner’s departure from the medical center.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/23/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all employees complete suicide prevention refresher training.
No. 3
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 that required members are assigned to the Women Veterans Health Committee.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/8/2021
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. 5
to Veterans Health Administration (VHA)
Closure Date: 11/8/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
Date Issued
|
Report Number
20-01141-145
|
Topics: Appointment Scheduling and Wait Times
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health
ensure Baltimore VA Medical Center leaders reevaluate their corrective action plan and adjust as needed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health make certain relevant staff receive appropriate training on recording wait times in the software.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/6/2022
The OIG recommended the under secretary for health strengthen reliability reviews of Emergency Department Integration Software data to mitigate the risk of inaccurate records.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The OIG recommended the under secretary for health establish routine oversight responsibilities for Veterans Integrated Service Network and facility leaders of emergency departments’ efforts to improve the reliability of their emergency department data.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health improve the monitoring of data for patients with the highest Emergency Severity Index levels of one or two receiving emergency care services.
Date Issued
|
Report Number
20-02968-170
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director reviews the process of evaluating the Community Living Center nursing staff’s competency for resident feeding and validates their ability to safely feed residents.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director ensures that Community Living Center nursing staff are trained on documentation requirements related to feeding of residents and verifies compliance with requirements.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director evaluates documentation of resident feeding, including identifying the staff member who feeds a resident, and takes action as indicated.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director verifies that a comprehensive review of the patient’s care and death is completed, and evaluates the usefulness of including the pictures and video of the chicken in the review, and takes action as indicated.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director ensures the Cardiopulmonary Resuscitative Committee evaluates identified issues and makes recommendations for improvement, confirms actions are implemented, and assesses the effectiveness of actions.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director verifies staff are aware of what constitutes an adverse event and the requirements to submit incident reports when witnessing or becoming aware of an adverse event.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director evaluates the circumstances surrounding the patient’s death to determine if an institutional disclosure is warranted
Date Issued
|
Report Number
20-01485-114
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The OIG recommended the area manager for the Central Texas Veterans Health Care System implement more effective automated inventory management tools.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The OIG recommended the area manager for the Central Texas Veterans Health Care System implement a more effective patch and vulnerability management program that can accurately identify vulnerabilities and enforce patch application.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The OIG recommended the area manager for the Central Texas Veterans Health Care System ensure compliance with the media protection standard operating procedure for all employees who work with media storage and ensure compliance with marking and sanitization provisions.
Date Issued
|
Report Number
19-08658-153
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/8/2023
Ensure facilities create and implement standard operating procedures that clearly define all Health Information Management and community care staff responsibilities and the procedures for accurately scanning, importing, and indexing non-VA medical records.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/8/2023
Require facility directors ensure that Health Information Management leaders provide or formally delegate training, quality checks, and quality assurance monitoring for community care staff responsible for medical record management.
Date Issued
|
Report Number
19-07719-113
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/6/2024
The OIG recommended the Maryland Health Care System director implement internal controls for healthcare system staff to submit and document approvals for all equipment requests in the Enterprise Equipment Request Portal before ordering and paying for equipment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/14/2022
The OIG recommended the Maryland Health Care System director implement a control requiring staff to justify the waiver of any healthcare system approvals ordinarily required to purchase equipment in the Enterprise Equipment Request Portal.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/11/2022
The OIG recommended the Maryland Health Care System director inform the deputy under secretary for health for operations and management for procurement and logistics of the internal control weakness in the Enterprise Equipment Request Portal and request a response regarding whether corrective action is necessary.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director require the logistics service to develop a plan for working with the prime vendor to ensure historical and current estimated supply data are timely, accurate, and meet healthcare system supply requirements.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director ensure the logistics service implements a plan to monitor for and correct unit conversion factor errors consistently and promptly.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/10/2024
The OIG recommended the Maryland Health Care System director establish processes and controls for cardholders to comply with the record retention requirements in the Federal Acquisition Regulation and VA’s Financial Policy, Volume XVI, “Charge Card Program.”
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The OIG recommended the Maryland Health Care System director ensure all staff are provided clear guidance on overtime approval and payment policies and procedures that meet VA requirements.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/8/2023
The OIG recommended the Maryland Health Care System director implement policies and procedures for supervisors to effectively monitor overtime worked and maintain documentation required to support related payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,552,000.00
Date Issued
|
Report Number
20-01270-154
|
Topics: Medical Staff Privileging Credentialing
● Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs base reprivileging decisions on service-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs ensure that ongoing professional practice evaluations for radiation oncologists include the minimum radiation oncology-specific criteria.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
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.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ determinations to continue privileges are based, in part, on results of ongoing professional practice evaluation activities.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/6/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Clinical Executive Board’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/6/2022
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 independent practitioners’ departure from the healthcare system.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures state licensing board reporting is initiated when a provider fails to meet generally accepted standards of practice.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
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 substance abuse, mental health problems or disorders, and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional 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. 12
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans are completed within the required time frame.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 3/2/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete annual suicide prevention refresher training.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that gynecological care coverage is available 24 hours a day, 7 days per week.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
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. 16
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief performs an annual risk analysis and reports the results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures the Sterile Processing Services supervisor enforces the daily cleaning schedule at the Fort Wayne campus.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Associate Director for 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. 19
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees who reprocess reusable medical equipment complete competency assessments.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services employees receive monthly continuing education.
Date Issued
|
Report Number
20-01487-142
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/31/2024
The OIG recommended the under secretary for health revise the Veterans Health Administration handbook to include detailed roles, responsibilities, and procedures for determining entitlement to and monitoring of the clothing allowance benefit.
No. 2
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health develop and initiate a plan to reevaluate veterans’ entitlement to recurring clothing allowance benefits in collaboration with the Veterans Benefit Administration.
Total Monetary Impact of All Recommendations
Open: $ 129,700,000.00
Closed: $ 9,810.00
Date Issued
|
Report Number
20-03075-138
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The under secretary for health direct the Medical Supplies Program Office to provide Veterans Integrated Service Network and VA medical facility chief logistics officers guidance on how to use and monitor the emergency and continuous supply strategies offered in prime vendors’ contingency plans to help mitigate acute emergency and continuous supply shortages during the current pandemic and future emergencies.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/6/2023
The Office of Acquisition, Logistics, and Construction direct the Strategic Acquisition Center’s Medical/Surgical Prime Vendor Program contracting officer to provide guidance to Veterans Integrated Service Network and VA medical facilities’ program contracting officer’s representatives on the emergency and continuous supply provisions in the contracts, and ensure contracting officers’ representatives inform network and facility managers of the strategies offered by the prime vendors.
Date Issued
|
Report Number
20-02967-121
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to implement internal control procedures to ensure the completeness and accuracy of the data in VA’s reports to the Office of Management and Budget and to Congress.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to execute data validation procedures to make certain that reports to the Office of Management and Budget and to Congress can be traced back efficiently to the source transactions.
Date Issued
|
Report Number
20-00541-133
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness develop and implement an enterprise wide plan to independently examine and validate the HR Smart position inventory.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness establish standard guidance to ensure positions are consistently approved, created, and maintained.
No. 3
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness implement enterprise wide oversight mechanisms to monitor position management on a regular basis and ensure the HR Smart position inventory is properly maintained.
No. 4
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health develop and implement a standardized national policy and procedures for the documentation and communication of staffing level approvals at VA medical facilities.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
The OIG recommended the acting under secretary for health publish detailed and prescriptive guidance establishing authoritative position management documents.
Date Issued
|
Report Number
20-03326-124
|
Topics: COVID-19
● Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health initiate efforts to revise or amend VHA Directive 1047 to clarify when changes to emergency cache activation procedures are appropriate, and develop the communication and documentation requirements for these situations to ensure all relevant parties—including medical facility directors and pharmacy chiefs—are aware of and comply with any changes to routine activation protocols as well as the responsibilities they maintain.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The OIG recommended that the under secretary for health establish minimum time frames, for example by assessing Emergency Pharmacy Service’s data on the typical length of time it takes to replenish emergency cache inventory items, by which the Emergency Pharmacy Service initiates resupply orders to make sure caches are fully stocked with unexpired inventory.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health make sure that the Emergency Pharmacy Service and the Watch Office are maintaining accurate and complete records of emergency cache activations.
Date Issued
|
Report Number
20-00178-24
|
Topics: System Development and Implementation
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, establish policies and procedures for joint governance by OIT and program offices on all information.
No. 2
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology require the Office of Information and Technology to develop controls for making certain the program management review process is consistently enforced for future information technology projects to deliver and sustain the intended outcomes and to ensure underperforming projects are identified for evaluation by the Program and Acquisition Review Council.
No. 3
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, reevaluate the risk determination for the Caregiver Record Management Application and determine if the system should be set to a security categorization level of high based on the personal health information and other sensitive data maintained therein.
No. 4
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology establish VA wide policies and responsibilities for managing VA information technology projects under the Development Operations process.
Date Issued
|
Report Number
20-03535-146
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates processes and implements a requirement as necessary that Emergency Severity Index level 2 patients do not remain in the Emergency Department waiting room.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates if additional quality reviews are needed due to failures identified in this report regarding the patient’s pre-code Emergency Department care, and takes action as indicated.
Date Issued
|
Report Number
18-02496-157
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/5/2023
The Under Secretary for Health ensures that the Veterans Health Administration competency process for locum tenens, newly hired specialty care providers, and newly hired service chiefs is evaluated to confirm that the results of the assessment accurately reflects the clinical competency of providers who are privileged, and takes action, as indicated.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health reviews current Veterans Health Administration credentialing and privileging policies to assess guidance related to service chiefs’ ongoing professional practice evaluation and takes action, as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health reviews Veterans Health Administration policies to ensure that if facility leaders elect to incorporate pathology 10 percent peer reviews into the performance evaluations of a Pathology and Laboratory Medicine Service Chief, those reviews are performed by a peer without a conflict of interest and takes action, as indicated.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/7/2022
The Under Secretary for Health evaluates the use and methodology of the Pathology and Laboratory Medicine Service 10 percent peer review for effectiveness as a quality management tool, and takes action, as indicated.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration guidance related to amended pathology reports’ terminology, use, and entry of such reports into patients’ electronic health records, and revises guidance, as appropriate.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health confirms that provisions are included in the Veterans Health Administration record modernization program that ensure amended pathology report alerts are directed to designated facility staff and leaders.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration quality management processes related to external, non-VHA pathology consultant assessments and ensures that facility leaders, the specialty care provider, and requesting providers are notified of the results of such reviews and a tracking process is in place.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The Under Secretary for Health confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, & Preparedness to determine whether administrative action is warranted for Veterans Health Administration leaders who did not adequately perform their duties with respect to the issues within this report, and takes action, as appropriate.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/5/2023
The Under Secretary for Health explores the development of a mandatory alcohol testing policy for individuals including healthcare workers who perform functions that would put patients at risk should the employee work while impaired.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The Under Secretary for Health evaluates Veterans Health Administration’s guidance related to impaired healthcare workers and ensures that it addresses the circumstances under which alcohol and or drug testing may be performed; the extent of a retrospective review of care if one is indicated; and the availability of advisors who are knowledgeable on the management of an impaired provider, and takes action, as indicated.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director verifies that peer references obtained during the reappraisal and reprivileging processes are in alignment with VHA Handbook 1100.19, Credentialing and Privileging.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director evaluates the psychological safety climate to ensure facility staff, patients, and the general public are empowered to report concerns and unsafe patient care without fear of reprisal and takes action, as needed.
Date Issued
|
Report Number
20-01267-148
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Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The Medical Center Director determines the reasons for noncompliance and ensures specific action items are recommended, implemented, and monitored when problems and opportunities for improvement are identified.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that an interdisciplinary committee reviews utilization management data as required.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete provider exit review forms within seven business days of licensed healthcare professionals’ departure from the medical center.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and effectiveness of pain management interventions.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
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 documented patient preference, within the required time frame.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women’s Health Advisory Committee meetings.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/1/2021
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. 8
to Veterans Health Administration (VHA)
Closure Date: 6/1/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures align with the manufacturers’ guidelines and instructions for use.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete valid competency assessments prior to reprocessing reusable medical equipment.