Date Issued
|
Report Number
20-03002-108
|
Topics: COVID-19
All Reports
Date Issued
|
Report Number
20-01386-107
|
Topics: Patient Safety
● Medical Staff Privileging Credentialing
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/2/2022
The Under Secretary for Health clarifies requirements for colonoscopy quality indicators for professional practice evaluation and ensures a process is in place to monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/17/2023
The Under Secretary for Health strengthens requirements for colonoscopy quality assurance monitoring that includes analysis of quality indicators to identify trends and monitors for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/12/2022
The Under Secretary for Health, in conjunction with the National Gastroenterology Program Director, evaluates implementation of standardized endoscopy software across Veterans Health Administration facilities where colonoscopies are performed and takes action as indicated.
Date Issued
|
Report Number
20-02667-93
|
Topics: Mental Health
● Suicide Prevention
● Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Phoenix VA Health Care System Director conducts a full review of the patient’s care to determine if administrative action is warranted, consulting with Human Resources and General Counsel offices as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Phoenix VA Health Care System Director ensures that staff complete suicide risk assessments consistent with Veterans Health Administration and Phoenix VA Health Care System policies.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Phoenix VA Health Care System Director ensures timely and accurate completion of electronic health record documentation.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Phoenix VA Health Care System Director evaluates the community care psychology consult authorization timeliness and takes action as warranted.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Phoenix VA Health Care System Director conducts a review of Primary Care Clinic missed appointment procedures and ensures patient follow-up and staff training, as appropriate.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Phoenix VA Health Care System Director evaluates scheduling accuracy of mental health community care psychology consults and takes action as appropriate.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Phoenix VA Health Care System Director ensures timely completion of behavioral health autopsies, consistent with Veterans Health Administration policy, and monitors for ongoing compliance.
Date Issued
|
Report Number
20-03210-83
|
Topics: Education and Loan Guaranty
Date Issued
|
Report Number
19-00652-79
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/9/2021
The Medical Center Director audits the Dental Service Chief’s relative value unit productivity metric for fiscal years 2018 and 2019 and determines whether any erroneous payments for performance were made and issues bills of collection if deemed appropriate.
Date Issued
|
Report Number
21-01116-98
|
Topics: COVID-19
Date Issued
|
Report Number
20-02717-85
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/17/2021
The Under Secretary for Health evaluates veteran access to VA Video Connect, including availability of equipment and reliable internet connectivity necessary to use VA Video Connect, and takes appropriate action.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/17/2021
The Under Secretary for Health reviews the provision of veteran VA Video Connect training and support, and takes appropriate action.
Date Issued
|
Report Number
20-00541-34
|
Topics: COVID-19
Date Issued
|
Report Number
20-00427-92
|
Topics: Patient Safety
● Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Under Secretary for Health maintains consistent acting or interim leaders and expedites hiring of permanent leaders at the Central Alabama Veterans Health Care System.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The VA Southeast Network Director ensures continued collaboration with the Central Alabama Veterans Health Care System to facilitate compliance with guidelines related to view alert management and monitors for ongoing efficiency and sustainability.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director will continue to evaluate and assess the Central Alabama Veterans Health Care System’s view alert management process, effectiveness of its action plan, and modify as indicated.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The Central Alabama Veterans Health Care System Director ensures that initial and ongoing provider training and support for the clinical management of view alerts is provided, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director issues guidance and ensures providers are trained on a clearly defined process for the designation of surrogates and the associated responsibilities, and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director evaluates the two cases discussed in this report to determine if an institutional disclosure or formal quality management review is needed and takes action accordingly.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on the unmanaged abnormal laboratory test and imaging results to include those that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on unscheduled community care consults that were discontinued after 90 days that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Central Alabama Veterans Health Care System Director ensures the development and implementation of a policy to address the communication of all test results to ordering providers, or designee, and to patients as required by Veterans Health Administration policy, and monitors compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director ensures that audits of abnormal laboratory and imaging test results, and unscheduled community care consults that were discontinued after 90 days, are completed to verify providers have managed the associated view alerts, and monitors compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Central Alabama Veterans Health Care System Director ensures that pending actions are completed for the 33 patient cases with clinical issues referred to the system by the Office of the Inspector General.
Date Issued
|
Report Number
20-01387-89
|
Topics: Patient Safety
● Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/24/2022
The Under Secretary for Health requires facility directors ensure that staff who reprocess colonoscopes at community-based outpatient clinics complete initial training within the required 90 days prior to independently reprocessing equipment and maintain documentation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/24/2022
The Under Secretary for Health requires facility directors confirm that sterile processing services staff who reprocess colonoscopes at community-based outpatient clinics receive ongoing continuing education through monthly in-services and maintain documentation.
Date Issued
|
Report Number
20-00102-73
|
Topics: Claims and Appeals
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 8/16/2021
The director of the Chicago VA regional benefits office ensure the errors identified by the review team are corrected.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 8/16/2021
The director of the Chicago VA regional benefits office monitor the effectiveness of the actions taken to improve the accuracy of administrative error corrections, and determine what additional measures, if any, are needed to make certain that claims processors understand how to apply national and local procedures for correcting administrative errors.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 67,000.00
Date Issued
|
Report Number
19-06147-50
|
Topics: Supplies and Equipment
● Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/23/2024
Direct the Medical Supplies Program Office to implement procedures requiring chief logistics officers at Veterans Integrated Service Networks to monitor facility processes for verification and certification of distribution fee invoices to ensure invoice accuracy prior to payment by the Financial Services Center.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/11/2025
Require Veterans Integrated Service Network directors to ensure their chief logistics officers develop distribution fee monitoring and review procedures for facility logistics audits and compliance reviews to ensure invoices are adequately reviewed, verified, and certified.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
Require Veterans Integrated Service Network directors to ensure facility chief logistics officers and contracting officer’s representatives review and update the election forms according to contract requirements and provide copies to the Medical/Surgical Prime Vendors for acknowledgment.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/11/2025
Require Veterans Integrated Service Network directors to ensure facility contracting officer’s representatives verify that distribution fee rates match with those on the election forms and pricing schedule by comparing transaction data from the vendors to VHA-maintained transaction data, and reconcile payments as appropriate.
No. 5
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/25/2022
Require the Strategic Acquisition Center to develop and add modifications to the Medical/ Surgical Prime Vendor-Next Generation contract requiring prime vendors to provide reports to VA medical facilities with detailed medical and surgical transaction data, fee amounts, and fee percentage rates applied to each transaction on distribution fee invoices.
No. 6
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/25/2022
Require the Strategic Acquisition Center contracting officer to work with the Medical Supplies Program Office to ensure that Medical/Surgical Prime Vendor contracting officer’s representatives are assigned to each VA medical facility.
No. 7
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/2/2022
Require the Strategic Acquisition Center to appropriately modify the Medical/Surgical Prime Vendor contract to define annual facility purchase as well as adding a provision for paying the annual facility purchase amount based on the estimated total spend until year-end reconciliation.
No. 8
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/2/2022
Require the Strategic Acquisition Center to also appropriately modify the Medical/ Surgical Prime Vendor contract to require the prime vendors—rather than the facility—to reconcile to annual facility purchases at the end of the year.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
Require the Medical Supplies Program Office to establish policy that clearly defines the source VA medical facilities should use to estimate their annual facility purchase amounts and determine the year-end amounts.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 9/3/2024
Require VA medical facilities to review their on-site representative fees paid during fiscal year 2018 and future years to ensure they were paid based on the actual annual facility purchase amounts, consistent with the Medical/Surgical Prime Vendor-Next Generation contract, and reconcile payment discrepancies as appropriate.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,700,000.00
Date Issued
|
Report Number
20-00130-86
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/3/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the development of a written policy that establishes and maintains a comprehensive environment of care program at the Veterans Integrated Service Network level.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures an annual review of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement are submitted to executive leaders for review and approval.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/25/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to executive leaders.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain the lead Women Veterans Program Manager completes annual site visits at each facility.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/25/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager completes assessments to identify staff education gaps related to women’s health and develops or adapts educational programs, materials, and/or resources where gaps are identified.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are posted within the required time frame.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Network Director evaluates and determines additional reasons for noncompliance and ensures that facility corrective action plans are developed within the required time frame.
Date Issued
|
Report Number
20-00421-63
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024
The under secretary for benefits creates written guidelines for tracking, identifying, notifying, registering, and exempting individuals required to take skills certification tests.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024
The under secretary for benefits establishes a tracking mechanism to ensure all eligible individuals required to take tests are identified and notified of testing dates at least 30 days prior to test administration.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/25/2023
The under secretary for benefits provides an update to the plan submitted to Congress explaining why all employees and supervisors who have claims-processing functions listed in the original plan are not subject to skills certification testing.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024
The under secretary for benefits implements a plan to ensure staff who failed their most recent skills certification test and remain in the same position are provided training from individual training plans to remediate the deficiencies in their skills and competencies.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024
The under secretary for benefits establishes an oversight plan to ensure training set out in approved training plans is provided to individuals who fail skills certification tests.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 12/5/2023
The under secretary for benefits notifies Congress of plans to take personnel actions against individuals who fail consecutive skills certification tests after remediation for the same positions in compliance with the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012.
Date Issued
|
Report Number
19-06902-23
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management directorate reevaluates all sample claims identified in this audit as not processed in accordance with Office of Community Care guidance, and takes appropriate corrective action as needed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/20/2022
The OIG recommended the under secretary for health ensures there is a contract requirement that the contractor’s employees must follow Office of Community Care guidance for processing non-VA care claims.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/20/2022
The OIG recommended the under secretary for health ensures the contractor’s standard operating procedures for claims processing are accurate and a mechanism is put in place to keep the contractor’s procedures updated to reflect current Office of Community Care claims processing procedures.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The OIG recommended the under secretary for health ensures the Office of Community Care develops and implements clear controls for reviewing and updating, if necessary, the quality assurance surveillance plan requirements at least annually
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management personnel make full use of the established communication tracking tool.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/2/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management leaders provide timely training and additional guidance to their staff and the contractor’s employees on applying and using standardized denial and rejection reasons, and employees follow procedures to process claims with no authorizations to ensure consistent and accurate claims processing.
Date Issued
|
Report Number
20-00563-68
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates documentation processes for entering the Breast Imaging-Reporting and Data System as primary diagnostic codes in the electronic health record and takes actions as necessary.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/8/2023
The Washington DC VA Medical Center Director evaluates the processes for notification of mammography exam results by ordering providers and takes actions as necessary.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director fully implements action plans for all issues listed in the September 2019 National Radiology Program Office site visit and monitors to completion.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/13/2021
The National Radiology Program Office ensures mammography programs have a comprehensive standard operating procedure manual and confirms compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director develops and implements a comprehensive standard operating procedure manual covering critical technical, clerical, and administrative functions for the facility’s Mammography Program.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates the oversight and training processes for the facility’s Mammography Program medical support assistant and takes actions as necessary.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates mammography technology staff training processes and takes actions to ensure mammography technology staff receive training through a formalized program.
Date Issued
|
Report Number
19-07053-51
|
Topics: Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance and controls to clinic staff on making determinations to send purchase requests and consult notifications to the appropriate purchasing agents.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance to purchasing agents on how to effectively evaluate biologic implant purchase requests for the correct funding source.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance to prosthetic agents to ensure they receive clinic staff consult notifications on all prosthetic purchases of biologic implants.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
Create a biologic implant cost code for general-purpose funds to improve funding accountability and potentially assist in ensuring all biologic implant use is tracked.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Direct the Procurement and Logistics Office to clarify guidance on the use of an approved inventory management system specific to biologic implants and the related VHA network, office, and facility staff responsibilities.
No. 6
to Veterans Health Administration (VHA)
Monitor facility compliance with the use of an approved inventory management system for completeness and accuracy.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/5/2023
Direct the Procurement and Logistics Office to ensure logistics staff perform inventory reviews of biologic implants, as required.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Monitor medical facility compliance with required reviews of on-site inventory.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/19/2024
Establish a structure for oversight responsibility that can provide guidance for tracking implanted biologics.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 4/3/2024
Create policies and procedures for facilities to follow as they implement effective controls for tracking biologic implants.
No. 11
to Veterans Health Administration (VHA)
Establish standardized systems and requirements for facility staff to appropriately record necessary biologic implant attributes for accurate and accessible tracking of recipients to advance patient safety.
Date Issued
|
Report Number
20-02959-62
|
Topics: COVID-19
● Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
Provide specific guidance for personnel in facilities and Veterans Integrated Service Network offices to report expired personal protective equipment supplies into the Response Monitoring Tool and refine the tool to allow the entry of expired supply levels on hand.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
Communicate effective verification measures for facilities and Veterans Integrated Service Networks to improve the reliability and consistency of reported personal protective equipment on-hand quantity and usage information.
Date Issued
|
Report Number
20-00295-61
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA),Veterans Health Administration (VHA)
Closure Date: 4/12/2021
The OIG recommended that the under secretary for benefits and the under secretary for health formalize interagency sharing processes between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care on how data and information will be shared between both offices to prevent payments from continuing to deceased spina bifida beneficiaries.
No. 2
to Veterans Benefits Administration (VBA),Veterans Health Administration (VHA)
Closure Date: 4/12/2021
The OIG recommended that the under secretary for benefits and the under secretary for health take the following actions establish clear written guidance on sharing beneficiary data between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care to ensure all entitled beneficiaries are enrolled in health care.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 5/7/2021
The OIG recommended that the under secretary for benefits institute standardized procedures to help the Veterans Benefits Administration’s national call center agents provide accurate and comprehensive information about spina bifida benefits.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The OIG recommended that the under secretary for health direct the Veterans Health Administration’s Office of Community Care to develop a process to ensure those beneficiaries who are not using the services for which they are eligible, or need assistance with locating those services, receive them.
Date Issued
|
Report Number
19-09129-76
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Under Secretary for Health should publish written guidance that clarifies roles and responsibilities of the national Cardiology program office, Veterans Integrated Service Networks, and Chief Medical Officers to review and opine on interventional cardiologist applicant’s qualifications for employment in those cases when facilities lack local interventional cardiology expertise and the facility’s Chief of Staff seeks subject matter expert opinion.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Veterans Integrated Service Network Director reviews circumstances that led to the failure
to respond to an OIG request for additional information and alters the person-dependent process
accordingly to ensure future OIG referrals are responded to timely and completely.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.