All Reports

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died
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19-08542-11
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Veterans Crisis Line Director conducts a comprehensive review of the Caller’s contacts and staff documentation on the day of the Caller’s death, consults with Human Resources and General Counsel Offices, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Veterans Crisis Line Director evaluates the effectiveness of current training for responders on lethal means assessment, takes action as warranted, and ensures supervisory oversight of lethal means assessments and related documentation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Veterans Crisis Line Director provides written guidance on responders’ documentation of supervisory consultation and considers implementing independent supervisory documentation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2022
The Veterans Crisis Line Director establishes policy and training for responders’ assessment of callers’ substance use and overdose risk, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Veterans Crisis Line Director expedites the decision whether to implement a standardized safety plan template and ensures completion of safety planning per Veterans Crisis Line standards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Veterans Crisis Line Director evaluates the criteria for supervisory follow-up including silent monitoring criteria and internal program review outcomes and takes action, as warranted.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Veterans Crisis Line Director implements a system to identify caller contacts that warrant root cause analysis or other internal reviews and tracks the review process to completion and includes interviews of all relevant staff.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2021
The Office of Mental Health and Suicide Prevention Program Executive Director expedites efforts to develop suicide prevention strategies for weekend and holiday callers who are identified at increased risk for suicide.
Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center in Dublin, Georgia
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20-00130-06

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are developed and documented in the Quality Executive Board
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in practitioner profiles.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that nonclinical staff receive the required Operation S.A.V.E. training during new employee orientation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required core members are assigned to and consistently attend Women Veterans Health Committee meetings.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief maintains an accurate file for all reusable medical equipment that includes the current manufacturers’ instructions for use.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
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’ instructions for use, are reviewed at least every three years, and are updated when there is a change.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that written records of weekly eyewash station testing are maintained.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and certifies that Sterile Processing Services staff complete and document liquid disinfectant solution testing to ensure the minimum effective concentration of the active ingredient is achieved.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/9/2021
The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that annual airflow testing is conducted in the Gastroenterology Sterile Processing Services storage room.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and verifies that eating, drinking, and food item storage is prohibited where the processes of decontamination, sterilization, or clean and sterile storage are performed.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Comprehensive Healthcare Inspection of the Ralph H. Johnson VA Medical Center in Charleston, South Carolina
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20-00132-04

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Chief of Staff determines the reasons for noncompliance and ensures that peer reviewers consistently use at least one of the nine aspects of care for evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners with similar training and privileges complete focused and ongoing professional practice evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum nuclear medicine-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2022
The Chief of Staff determines the reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that Clinical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Medical Center Director determines the reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and makes certain that flooring in the inpatient behavioral health unit seclusion room is made of material that provides cushioning.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that managers maintain a safe and clean environment.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual training thereafter.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2020
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.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders and is comprised of required core members who consistently attend meetings.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2020
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2020
The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is stored.
Management of the Ophthalmology Clinic and Patient Safety Reporting Concerns at the VA Central Iowa Health Care System in Des Moines
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20-01326-08
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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: 8/2/2021
The VA Central Iowa Health Care System Director ensures Ophthalmology Clinic staff are trained on how to identify, analyze, and report patient safety events and close calls.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2021
The VA Central Iowa Health Care System Director ensures that patient safety events and close calls are entered into the Joint Patient Safety Reporting system, and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The VA Central Iowa Health Care System Director develops an action plan to address the culture within the Ophthalmology Clinic and monitors effectiveness.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The VA Central Iowa Health Care System Director reviews the oversight and management of the Ophthalmology Clinic, makes recommendations for improvement, and monitors effectiveness.
Deficiencies in Care and Excessive Use of Restraints for a Patient Who Died at the Charlie Norwood VA Medical Center in Augusta, Georgia
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19-08106-273
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Topics:  Patient Safety ● Mental Health ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2021
The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and determines whether an institutional disclosure is warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures Emergency Department and Inpatient Medical Unit staff performs vital sign assessment and monitors patients who received sedating medications.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nurses accurately document medication administration.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit staff implement patient restraint management according to the Charlie Norwood VA Medical Center policy, including documentation, physician orders, and education requirements.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nursing staff communicate with providers regarding patients’ refusal of treatment.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director strengthens Inpatient Medical Unit nicotine replacement therapy processes and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2021
The Charlie Norwood VA Medical Center Director strengthens processes to include the patient, family members, or surrogate in informed consent procedures and treatment decisions, as appropriate, and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2021
The Charlie Norwood VA Medical Center Director evaluates the inpatient mental health consult process, and addresses timeliness and completion of decision-making capacity consult requests, and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director consults with the Office of General Counsel regarding policies related to the management of patients presenting under a Form 1013 and advises policy and practices consistent with Georgia State mental health laws and takes action, as appropriate.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2021
The Charlie Norwood VA Medical Center Director ensures staff adhere to inter-facility transfer policies and procedures, including accurate communication of patients’ restraint management status, and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures that a consultation liaison psychiatrist is included on code gray teams at both divisions.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director evaluates inpatient mental health consult staffing and establishes a plan to ensure adequate staffing to complete consult requests as required without outpatient mental health appointment cancellations and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee reviews patient record flags and provides input into patients’ management to mitigate violence, as required by Veterans Health Administration, and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2021
The Charlie Norwood VA Medical Center Director makes certain that staff receive education in code gray policy and procedures, including completion of the code gray evaluation form, and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2021
The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee provides oversight of the code gray team activities, as required by Charlie Norwood VA Medical Center policy, and monitors compliance.
VA’s Noncompliance with Preaward Review Requirements for Sole-Source Proposals for Healthcare Services
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18-04150-261

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The OIG recommends the VHA executive director for procurement ensures contracting officers are requesting preaward reviews for all sole source healthcare resource contracts with an annual value at or above $400,000 in keeping with the May 2018 revisions to VA Directive 1663.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
The OIG recommends the VHA executive director for procurement require an OIG preaward review for all interim contracts that exceed the $400,000 annual threshold.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
The OIG recommends the VHA executive director for procurement mandate an immediate postaward review for any sole source contract awarded on an interim basis as an emergency contract.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,101,555.00
Lack of Adequate Controls for Choice Payments Processed through the Plexis Claims Manager System
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19-00226-245
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care Define the terms “verifiable usual and customary charges that are billed to payers other than VA” for the PC3/Choice contract claims.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure future community care programs have applicable definitions and guidance for claims without a Medicare or VA fee schedule rate to avoid reimbursements that pay at “billed charges.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care create a master usual and customary rate schedule to be used for reimbursement of community care claims without a Medicare or VA fee schedule rate to control program costs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care provide parties responsible for reimbursing PC3/Choice and future community care program claims with usual and customary rate price schedules and a formal written policy on the proper application of those rates.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care establish controls for verifiable usual and customary rate payment methodology and establish a payment review process to ensure usual and customary rates are properly applied to the PC3/Choice and future community care program payments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure payment-rate schedules used by the Plexis Claims Manager and future payment systems to support the PC3/Choice and future community care contracts are current, accurate, and complete to prevent overpayments.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure that the Office of Community Care determines an appropriate reimbursement process for the identified pass-through errors in this report.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure the Office of Community Care establishes formal policies and procedures to identify and recover overpayments from PC3/Choice third-party administrators for improperly billed claims.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 205,100,000.00
Greater Consistency Study Participation and Use of Results Could Improve Claims Processing Nationwide
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19-07062-255

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/19/2020
The under secretary for benefits directs the Compensation Service to provide the Administration Results Report for each consistency study to the Office of Field Operations and to managers at all regional offices.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2021
The under secretary for benefits ensures the Office of Field Operations develops a process to monitor regional offices to ensure maximum employee participation in consistency studies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2021
The under secretary for benefits makes certain the Office of Field Operations establishes a requirement for regional office managers to review consistency study results and develop a plan for corrective action based on the performance of their regional office.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2021
The under secretary for benefits requires the Office of Field Operations to develop a follow-up process to confirm all corrective actions identified are completed by regional office managers.
Deficiencies in Pharmacy and Nursing Processes at the Southeast Louisiana Veterans Health Care System in New Orleans
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19-07854-272
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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: 3/9/2021
The Southeast Louisiana Veterans Health Care System Director educates pharmacy staff on the Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies related to unaffixed medication labels, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2022
The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff comply with the five rights of medication administration prior to administering medications.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff administer medications in accordance with physician orders as required by Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director confirms that the intensive care unit nursing staff comply with the Southeast Louisiana Veterans Health Care System policy for high-alert and high-risk medications.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director validates compliance with obtaining locked boxes to secure controlled substances for intravenous medications administered on the inpatient units.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director verifies that facility staff are aware of how to submit Joint Patient Safety Reports that contain complete and accurate information.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if peer reviews of relevant clinical staff are warranted.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if an institutional disclosure is warranted.
Nurse Staffing, Patient Safety, and Environment of Care Concerns at the Community Living Center within the San Francisco VA Health Care System in California
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20-00005-271
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Topics:  Staffing ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures that the Associate Director for Patient Care Services performs a comprehensive review of Community Living Center nurse staffing methodology, retrains the Nurse Staffing Methodology Coordinator, and develops staffing methodology processes that reflect the needs of the Community Living Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director continues efforts to recruit and hire for Community Living Center nursing assistants and ensures that alternate staffing strategies are consistently available to meet target nursing hours per patient day until optimal staffing is attained.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director confers with facility nursing leadership and the Office of Human Resource Management to identify and mitigate barriers to nursing assistant staff retention and recruitment and takes appropriate action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director consults with VA Sierra Pacific Network and VA Central Office to determine the number and status of approved Community Living Center operating beds and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2021
The San Francisco VA Health Care System Director ensures a review of the episode of care related to Resident B’s elopement to determine if a formal quality management review is needed and takes action accordingly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director evaluates the requirement for Community Living Center registry nursing assistant staff access to the electronic health record system, involving the Office of General Counsel and the Network Contracting Office 21 as appropriate and takes action if needed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures that Environmental Management Services provides Community Living Center staff a clear communication pathway to request assistance for all shifts and confirms its functionality.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director establishes comprehensive quality monitoring of the ongoing issue of the presence of flying insects in the Community Living Center, and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures that Community Living Center staff adhere to Veterans Health Administration hand-hygiene policies and ensures that corrective actions are initiated when hand-hygiene performance falls below established thresholds.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures a comprehensive review of the registry agency agreement for performance, the provision of nursing assistants as requested, and determines if the agreement meets the needs of the Community Living Center.
Deficiencies in Provider Oversight and Privileging Processes at the Carl Vinson VA Medical Center in Dublin, Georgia
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19-07828-265
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with the oversight of medical staff, including those with possible physical impairments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with privileging policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with state licensing board reporting policies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2021
The Carl Vinson VA Medical Center Director evaluates concerns that the urologist has a possible physical impairment, consults with Human Resources, and takes action, if indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Carl Vinson VA Medical Center Director reviews current clinical care review processes, identifies areas of noncompliance with facility bylaws, and takes action to ensure compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2021
The Carl Vinson VA Medical Center Director reviews current reduction of privileges processes, identifies areas of noncompliance, and takes action to ensure compliance with Veterans Health Administration policy.
Misuse of Funds, Improper Disposal of Equipment, and Destruction of Records
|
17-00126-267
|
Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2020
The deputy undersecretary for health for the Office of Community Care, with the assistance of the Office of General Counsel as appropriate, ensures that the Office of Community Care’s Equal Employment Opportunity Office and its Revenue Operations group are correctly interpreting and complying with VA Handbook 5975.5 and VA’s Financial Policies and Procedures with regard to the administration of Special Emphasis Programs, including the purchase of food.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2020
The principal executive director and chief acquisition officer of the Office of Acquisition, Logistics and Construction and the deputy undersecretary for health for the Office of Community Care ensure that their staff are appropriately trained on requirements for compliance with VA Directive 6371 governing the destruction of temporary paper records.
The Veterans Health Administration’s Governance of Robotic Surgical System Investments Needs Improvement
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19-07103-252
|
Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2023
The OIG recommended the under secretary for health update the high cost, high tech medical equipment application to provide clearer instructions on preparing requests and providing supporting documentation for robotic surgical systems. The application and instructions should be disseminated to medical facilities, Veterans Integrated Service Networks, and responsible central office organizations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2023
The OIG recommended the under secretary for health establish controls to ensure information in high cost, high tech medical equipment applications is reviewed and validated before recommending final approval to the assistant deputy under secretary for health for administrative operations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2022
The OIG recommended the under secretary for health evaluate the need and justification of the 10 robotic surgical systems at VA medical facilities that were acquired without approval by the assistant deputy under secretary for health for administrative operations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The OIG recommended the under secretary for health develop guidance for accurately and consistently coding robotic surgical procedures in the Veterans Health Information Systems and Technology Architecture.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2021
The OIG recommended the under secretary for health evaluate the need for the National Surgery Office to obtain robotic surgical procedure data from the system manufacturer to assess and validate the use of the systems at VA medical facilities.
Financial Controls Related to VA-Affiliated Nonprofit Corporations: Idaho Veterans Research and Education Foundation
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18-00711-251
|
Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
The Boise VAMC director confers with the Office of General Counsel to determine whether administrative action should be taken against the nonprofit’s current executive director concerning: (a) the processing of salary increases for the former executive director and herself without written authorization and performance evaluations as required by IVREF policies and (b) the failure to report the former executive director’s conduct regarding the salary increase to the board of directors.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Boise VAMC director makes certain the Idaho Veterans Research and Education Foundation board of directors implements controls requiring two or more responsible officials to provide oversight of all salary and pay rate changes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Boise VAMC director ensures the Idaho Veterans Research and Education Foundation board of directors implements controls for the use of credit cards and the receipt, review, and reconciliation of credit card statements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Boise VAMC director establishes procedures that require the Research and Development Budget Office staff to review VA-affiliated nonprofit corporation invoices to confirm services were performed or goods were received in accordance with Intergovernmental Personnel Act agreements before approving invoices for payment.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2022
The Boise VAMC director institutes procedures to make certain the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 112,400.00
Pharmacy Process Concerns and Improper Staff Communication at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia
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20-01102-266
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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: 4/26/2021
The Hunter Holmes McGuire VA Medical Center Director ensures prescriber education on prior authorization drug request consultation procedures including consult documentation options, urgency level communication, patient notification, and appeals processes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director promotes mental health prescribers’ utilization of the prior authorization drug request process in consideration of the medication plan most effective for each patient.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director ensures that electronic health records are reviewed for improper entries, and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Hunter Holmes McGuire VA Medical Center Director conducts a review of staff improper electronic health record entries and electronic mail and consults with Office of Human Resources to determine if administrative action is warranted, and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director evaluates ways to improve the workplace relationships between Mental Health and Pharmacy Services staff, including consultation with the Veterans Integrated Services Network or the National Center for Organizational Development, and takes actions as appropriate.
Mismanagement of Emergency Department Care of a Patient with Acute Coronary Syndrome at the Robert J. Dole VA Medical Center in Wichita, Kansas
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20-01318-258
|
Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures that Emergency Department physicians receive training on the facility’s acute coronary syndrome protocol and verifies that ST-elevation myocardial infarction time goals are monitored, and improvements implemented as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director makes certain a facility policy that is applicable to all patient care areas outlines standardized processes for safe and timely interfacility transfers, including communication of appropriate transport services needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director conducts an analysis of the contributing factors that led to the delay in the patient’s interfacility transfer and takes action as necessary to improve identified deficiencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director ensures the newly implemented Emergency Department Interfacility Transfers policy is reviewed and updated to include improvements as data are obtained from the interfacility transfer analysis.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director makes certain that Emergency Department and Health Administrative Service staff are trained on the Emergency Department Interfacility Transfers policy, the updated service agreement between Cardiology and Emergency Departments, and interfacility transfer process and monitors the transfer process, including timeliness of transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures the Critical Care Committee evaluates all concerns identified during code events, makes recommendations for improvement, confirms actions are implemented, and assesses effectiveness of actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures the Chief, Quality Management is a member of the Critical Care Committee, develops a process to address problems in obtaining the assistance of Emergency Medical Services or use of the 911 call system, and assesses the effectiveness of the process.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The VA Heartland Network Director reviews the peer reviews of physicians who provided care to the patient to determine if a focused clinical review by an independent reviewer is warranted and takes actions as necessary.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director reviews the patient’s care provided in the Emergency Department and the circumstances of the interfacility transfer to determine if an institutional disclosure is warranted.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2021
The Robert J. Dole VA Medical Center Director ensures interfacility transfer data are collected, analyzed, and incorporated into the Robert J. Dole VA Medical Center’s quality management program as required by Veterans Health Administration policy.
Improved Oversight of Surgical Support Elements Would Enhance Operating Room Efficiency and Care
|
18-06039-229
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Topics:  Clinical Care Services Operations ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider developing an oversight mechanism that includes the VISN Surgery Integrated Clinical Community Chair in the monitoring of medical facility operating room efficiency and surgical support element problems and ensures VISN Directors hold medical facilities accountable when these problems persist and reduce operating room efficiency.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider periodically analyzing two to three years of operating room efficiency data to identify medical facilities that have not consistently met National Surgery Office efficiency goals and assess surgical support element problems impacting patients and operating room efficiency.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office clarify the intent of the current utilization measure and assess other utilization measures other than staffing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2020
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office gather as part of its capacity measure information about operating room closures or reduced usage, including the reasons for the closures or curtailment of surgeries.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The OIG recommended the Under Secretary for Health consider identifying surgical support element best practices used by efficient facilities and ensure less efficient medical facilities, where appropriate, implement these practices to address problems, reduce surgical cancellations and delays, and minimize patient risks.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring medical facility surgical work groups to discuss the National Surgery Office Efficiency goals and their facility’s performance with support services, such as logistics, sterile processing service, and environment management service, at least quarterly and ensure they all work proactively and collaboratively to address surgical support element problems.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 30,000,000.00
Date of Receipt of Claims and Mail Processing During the COVID-19 National State of Emergency
|
20-02825-242
|
Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/12/2020
Determine what additional actions are needed to make certain that staff understand how to accurately apply the most current guidance to the date of receipt recorded for claims received during the national state of emergency and implement those actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/24/2022
Conduct a review to ensure claims received and completed from March 1, 2020, had the correct date of entitlement applied.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/12/2020
Reevaluate guidance for the date of receipt recorded for claims without a postmark received during the national state of emergency.
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