All Reports

Safety Concerns When Providing Care in the Community at the VA Southern Nevada Healthcare System in North Las Vegas
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19-09410-203
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Topics:  VA Police

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and makes changes to ensure staff and supervisors are aware of and follow reporting requirements arising from off-facility patient disruptive behavior incidents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and implements changes to address traumatic injury needs of staff who may be experiencing an emotional or mental health injury as a result of a work related incident.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and implements changes to ensure timely notification of threats to targeted staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies for the placement of behavioral flags and makes changes to ensure patient record flags are placed to address immediate safety issues.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The VA Southern Nevada Healthcare System Director ensures that VA Southern Nevada Healthcare System VA police fulfill their obligation to fully participate with the Disruptive Behavior Committee, including the triage of Disruptive Behavior Response System entries, and confirms that potential criminal or safety issues are timely addressed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The VA Southern Nevada Healthcare System Director reviews the VA Southern Nevada Healthcare System Housing and Urban Development-Veterans Affairs Supporting Housing staffing levels and practices to ensure staffing and training safely meet the demands of the program.
Comprehensive Healthcare Inspection of the John J. Pershing VA Medical Center in Poplar Bluff, Missouri
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19-09416-186
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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: 11/19/2020
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.
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 clinical managers define and document expectations for focused professional practice evaluations in provider profiles prior to assessment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that first- or second-line supervisors complete provider exit review forms within seven calendar days of a provider’s departure from the medical center.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavior risk assessment that includes a history of substance abuse, psychological factors, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
No. 5
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 makes certain that providers document justification for concurrent opioid and benzodiazepine medication therapy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff determines the reason for noncompliance and make certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that healthcare providers obtain and document informed consent consistently for patients prior to initiating long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up of patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Interim Medical Center Director determines the reasons for noncompliance and ensures that the Pain Management Sub-Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians conduct four follow-up appointments, either face-to-face or telephonic with documented consent, within the required time frame.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain staff receive annual suicide prevention refresher training.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Interim 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 CBOCs have only one designated provider.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee is comprised of the required core members.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/5/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
Comprehensive Healthcare Inspection of the Harry S. Truman Memorial Veteran’s Hospital in Columbia, Missouri
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19-06864-183
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director determines reasons for noncompliance and ensures that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2021
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 calendar days of licensed health care professionals’ departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavior risk assessment on all patients prior to initiating long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients when initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff determines reasons for noncompliance and ensures healthcare providers follow up with patients within the required timeframe after initiating long-term opioid therapy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that staff receive annual suicide prevention refresher training.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that practitioners complete and document all required elements of life-sustaining treatment plan progress notes.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and certifies that a multidisciplinary committee is established to review proposed life-sustaining treatment plans.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Advisory Committee For Women Veterans includes required core members.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2021
The Associate Director for Patient Service evaluates and determines any additional reasons for noncompliance and makes certain that Chief of Sterile Processing Services completes valid competency assessments for staff reprocessing reusable medical equipment.
Waste and Abuse by the Former Assistant Secretary for Human Resources and Administration
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19-00230-190

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/9/2021
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction requires in any award made on a noncompetitive basis that the contracting officer obtain a written disclosure and certification by the program sponsor, contracting officer’s representative, and other staff involved in the procurement as appropriate, disclosing any personal or professional relationship between such staff and vendor personnel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/2/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the conduct and performance of the contracting officer, the Agency Competition Advocate, and the two higher-level supervisors involved in this procurement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/30/2020
The Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness determines what administrative action should be taken, if any, with respect to the conduct and performance of the HR&A Program Director and the Contracting Officer’s Representative.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/2/2020
VA’s Senior Procurement Executive determines what action, if any, should be taken with respect to the contracting officer’s warrant consistent with the authority granted by VA Acquisition Regulation § 801.690-6.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 12/14/2020
The Acting General Counsel reviews the circumstances of this procurement and uses that information to help determine whether it is appropriate for counsel to sign attestations on Justification and Approval forms, and issues policy guidance in accordance with that determination.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC),General Counsel (OGC)
Closure Date: 12/2/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction, in consultation with the Office of General Counsel, reviews the Small Business contract to determine what actions should be taken, if any, to recover funds or otherwise address the waste of VA funds.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/2/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the contracting officers’ acceptance of substitute performance that provided no value to VA.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/30/2020
The Assistant Secretary of Human Resources and Administration (HR&A) / Operations, Security, and Preparedness determines what administrative action to take, if any, with respect to the Contracting Officer Representative’s failure to perform diligence sufficient to identify the cloud-computing issues associated with this procurement.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,999,500.00
Comprehensive Healthcare Inspection of the Tomah VA Medical Center in Wisconsin
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20-00082-189

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff determines the reasons for noncompliance and ensures all staff complete annual suicide prevention refresher training.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are included in the Women Veterans Health Committee charter and attend the quarterly meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Review of Highly Rural Community-Based Outpatient Clinics' Limited Access to Select Specialty Care
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19-00017-191
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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: 10/7/2021
The Under Secretary for Health completes a specialty care needs assessment for highly rural community-based outpatient clinics to include internet bandwidth and telehealth equipment and develops options for the delivery of safe patient care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Under Secretary for Health ensures that the Veterans Health Administration Site Tracking system validation process is completed by each Veterans Integrated Service Network as required and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Under Secretary for Health ensures that facilities and Veterans Integrated Service Networks maintain accurate and current information on websites as required and monitors for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/13/2021
The Under Secretary for Health completes an assessment to determine whether highly rural community-based outpatient clinics that are located in a non-VA community hospital or health care center are fully utilizing the resources available at the non-VA facilities and takes action as indicated.
Anesthesia Provider Practice Concerns at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina
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19-09377-192
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The Under Secretary for Health initiates review of the Veterans Health Administration’s credentialing policy to determine the need for requirement clarification related to prior employment history to include applicant listing of locum tenens contracting companies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The W. G. (Bill) Hefner VA Medical Center Director ensures credentialing and privileging staff verify applicants’ information within the required timeframe outlined by Veterans Health Administration policy and monitors for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The W. G. (Bill) Hefner VA Medical Center Director ensures annual proficiency reports are completed and maintained consistent with Veterans Health Administration requirements and monitors for compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The W. G. (Bill) Hefner VA Medical Center Director ensures all available performance and competency information is provided to the Professional Standards Board for consideration during provider probationary and reprivileging reviews and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The W. G. (Bill) Hefner VA Medical Center Director ensures that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
Inadequate Care by a Clinical Pharmacy Specialist and a Primary Care Provider at the Tennessee Valley Healthcare System in Nashville
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19-07543-178
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Veterans Integrated Service Network Director conducts a comprehensive review of the patient’s care including collaboration among Patient Aligned Care Team members and takes action as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Tennessee Valley Healthcare System Director ensures facility staff are aware of and follow Veterans Health Administration Directive 1088, Communicating Test Results to Providers and Patients, specifically the requirement for the ordering clinician to communicate all test results to patients.
Deficiencies in Evaluation, Documentation, and Care Coordination for a Bariatric Surgery Patient at the VA Pittsburgh Healthcare System in Pennsylvania
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19-09436-185
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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: 2/18/2021
The VA Pittsburgh Healthcare System Director considers developing a facility policy for bariatric surgery to include preoperative medical and mental health evaluations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The VA Pittsburgh Healthcare System Director ensures that bariatric patients receive all preoperative medical and mental health evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The VA Pittsburgh Healthcare System Director reviews the documentation error noted in this report and takes action as appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2021
The VA Pittsburgh Healthcare System Director provides education to staff on how to correct documentation errors and the requirement to follow facility policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The VA Pittsburgh Healthcare System Director ensures interdisciplinary discussions about preoperative bariatric patients are documented in the electronic health record and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2021
The VA Pittsburgh Healthcare System Director considers a programmatic review of the Bariatric Surgery Program to ensure patients receive a comprehensive preoperative evaluation and postoperative follow-up care.
Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan
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20-00067-172
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff determines the reason(s) for noncompliance and ensures that ongoing professional practice evaluations include service-specific criteria.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Executive Committee minutes consistently reflect the review of professional practice evaluation results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing for patients prior to initiating or continuing long-term opioid therapy and periodically thereafter.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the VISN Sterile Processing Services Management Board.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that include at least two methods of verification for reprocessing reusable medical equipment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
VA Should Examine Options to Expand Retail Pharmacy Drug Discounts
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19-07281-105
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2021
The OIG recommended the Under Secretary for Health conduct a formal analysis of VHA’s Office of Community Care prescription drug programs to determine what steps VA would need to take to require drug manufacturers to provide Big 4 prices for covered prescription drugs purchased for CHAMPVA and any other VA Community Care programs that use a retail pharmacy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2021
The OIG recommended the Under Secretary for Health collaborate with the Office of Regulatory and Administrative Affairs and, if determined appropriate, pursue any proposed statutory or other changes needed to provide VA with the appropriate legal authority to purchase all prescription drugs through retail pharmacies at the Big 4 prices.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 345,100,000.00
Attorney Misconduct, Inadequate Supervision, and Mismanagement in the Office of General Counsel
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18-06501-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC),Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 12/18/2020
The Acting VA General Counsel confers with the Designated Agency Ethics Official and the Assistant Secretary for Human Resources and Administration to determine whether any remaining administrative action should be taken with respect to the Attorney’s conduct.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 12/18/2020
The Acting VA General Counsel confers with the Designated Agency Ethics Official to determine whether VA should take any further action with respect to the Attorney’s representation of private parties in matters currently pending in U.S. federal court in which the United States is a party or has a direct and substantial interest to address any other government ethics issues.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 12/18/2020
The Acting VA General Counsel determines what, if any, obligation the Office of General Counsel has with respect to reporting the Attorney’s conduct to the relevant disciplinary authority under Rule 8.3 of the New York Rules of Professional Conduct or any other governing authority.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 10/5/2021
The Acting VA General Counsel determines the appropriate action to take, if any, with respect to Mr. Hogan’s failure in his official duties to take appropriate action.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 7/1/2021
The Acting VA General Counsel determines the appropriate action to take, if any, with respect to the Deputy Chief Counsel’s failure in his official duties to take appropriate action.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 10/5/2021
The Acting VA General Counsel confers with VA’s Designated Agency Ethics Official to revise its November 8, 2019 memorandum. The revision should at a minimum (a) emphasize all criminal conflict of interest statutes relevant to outside employment, (b) ensure appropriate time for supervisory review of confidential financial disclosure reports to identify potential conflicts or other issues, (c) identify the official responsible for ensuring that the annual risk assessment focused on outside activities is completed on an annual basis to assist Chief Counsel in identifying employees with outside employment, (d) engage employees with outside employment in formal discussions regarding applicable ethical rules and the consequences of noncompliance, and (e) document the annual meetings and formal discussions they have with employees.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 7/1/2021
The Acting VA General Counsel confers with VA’s Designated Agency Ethics Official to determine whether VA should consider implementing a supplemental agency regulation requiring VA employees, or any category of employees, to disclose and obtain prior approval before engaging in any outside activities for which they receive compensation in accordance with 5 C.F.R. § 2635.803.
Overtime Use in the Office of Community Care to Process Non-VA Care Claims Not Effectively Monitored
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18-06292-117
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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: 12/23/2020
The Office of Community Care completes a review of the OIG identified employees who had no claims processing production or activity in the Fee Basis Claims System during overtime hours to determine whether the employees’ conduct requires disciplinary or other corrective action, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The Office of Community Care establishes and implements controls for Payment Operations and Management supervisors to effectively monitor and assess staff productivity during overtime hours to mitigate the risk of overtime abuse.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Payment Operations and Management directorate clarifies and communicates nurse productivity standards and requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Payment Operations and Management directorate develops and implements formal guidance for its staff on the appropriate use of overtime, and the controls needed for monitoring compliance.
Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka
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19-06870-175
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing ● Suicide Prevention

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The System Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are documented in Quality, Safety, and Value Board minutes when problems or opportunities for improvement are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff determines the reason(s) for noncompliance and ensures that peer reviewers consistently use at least one of the nine aspects of care for evaluations and address the initial screener’s concern.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths within 24 hours of admission are peer reviewed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that final peer reviews are completed within 120 calendar days from the date it is determined a peer review is required and any necessary extensions are approved in writing by the System Director.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analyses is reviewed quarterly by the Medical Executive Board.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The System Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements and be properly documented in the VHA Patient Safety Information System.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in the provider profiles.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum required gastroenterology- and pathology-specific criteria for focused professional practice evaluations of licensed independent practitioners.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that Medical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2023
The System Director 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’ departing the healthcare system and include the signature of the first- or second-line supervisor in the properly designated area.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures employees’ ability to access safety data sheet information.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director determines the reasons for noncompliance and ensures that clean/sterile storerooms are secured.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures damaged wheelchairs are repaired or removed from service.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director determines the reason(s) for noncompliance and ensures areas are consistently stocked with medical supplies typically needed to meet patient care needs.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2021
The Assistant Director evaluates and determines any additional reasons for noncompliance and makes certain that panic alarms are tested and that deficiencies identified from the testing are addressed, including staff education.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director determines the reason(s) for noncompliance and ensures that deficiencies observed during Comprehensive Environment of Care Rounds are correctly documented in the Comprehensive Environment of Care Assessment and Compliance Tool and followed until completion.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that Wyandotte County VA Clinic managers maintain a safe and clean environment by addressing the deficiencies identified by the inspection.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that personally identifiable information is protected when transporting information or specimens from the clinics.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers obtain and document informed consent consistently for patients who are initiating long-term opioid therapy.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator ensures completion of at least five outreach activities each month.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff evaluates and determines reasons for noncompliance and ensures that mental health providers consistently contact or attempt to contact patients flagged as high risk for suicide who miss mental health or substance abuse appointments and properly document those efforts.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and reasons for noncompliance and makes certain that the mental health provider and the Suicide Prevention Coordinator collaborate to determine next steps for patients flagged as high risk for suicide when attempted contact is unsuccessful after missed mental health or substance abuse appointments.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Chief of Staff determines the reason(s) for noncompliance and ensures that Suicide Prevention Safety Plans include an assessment of patients’ access to opioids and a discussion of safety and overdose risks.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that each CBOC has at least two designated women’s health primary care providers or arrangements for leave coverage when CBOCs have only one designated provider.
No. 31
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend the Women Veterans Health Committee that meets at least quarterly and reports to executive leaders.
No. 32
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Service Chief maintains an accurate file for all reusable equipment that includes current manufacturers’ instructions for use.
No. 33
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures are kept current and maintained as required, which includes alignment with manufacturers’ guidelines and instructions for use, review at least every three years, and update when there is a change in process or the manufacturer’s instructions for use.
No. 34
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief consistently performs an annual risk analysis and reports the analysis to the Veterans Integrated Service Network Sterile Processing Service Management Board.
No. 35
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is reprocessed.
No. 36
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that endoscopes are stored properly.
No. 37
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines reasons for noncompliance and ensures that all current Sterile Processing Services employees complete Level 1 training and all new employees complete Level 1 training within 90 days of hire.
No. 38
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines reasons for noncompliance and ensures that the Chief of Sterile Processing Services documents completion of competencies for staff prior to performance of reprocessing duties.
No. 39
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Deficiencies in Virtual Pharmacy Services in the Care of a Patient
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19-07827-182
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2021
The Under Secretary for Health ensures a review of the pharmacy care provided for the patient and consult with the Human Resources Department regarding administrative action, if warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2021
The Under Secretary for Health develops a standardized Veterans Health Information Systems and Technology Architecture menu for Meds by Mail Virtual Pharmacy Services clinical pharmacists and ensures training and access to clinical information to perform the functional statement duties.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2021
The Under Secretary for Health ensures consistency between Virtual Pharmacy Services Meds by Mail clinical pharmacists’ functional statements and position responsibilities.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2021
The Under Secretary for Health evaluates the Meds by Mail Virtual Pharmacy Services performance metrics, determines a reasonable productivity benchmark, and establishes additional metrics as appropriate.
No. 5
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 6/18/2020
The Under Secretary for Health establishes program management and quality assurance objectives for Virtual Pharmacy Services that define the reporting frequency and structure, and monitors compliance with contract terms.
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