Date Issued
|
Report Number
20-02221-120
|
Topics: COVID-19
All Reports
Date Issued
|
Report Number
19-09126-115
|
Topics: Financial Management
Date Issued
|
Report Number
19-08374-112
|
Topics: Mental Health
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Under Secretary for Health ensures the clarification of policy regarding emergent mental health services extension request procedures including expected timeframes and patient notification processes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/31/2020
The Under Secretary for Health expedites the establishment of policy regarding follow-up of patients identified by the Recovery Engagement and Coordination for Health –Veterans Enhanced Treatment program and no longer receiving Veterans Health Administration services.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Coatesville VA Medical Center Director ensures compliance with the 90-day emergent mental health services extension request policies and procedures, as required by the Veterans Health Administration.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Coatesville VA Medical Center Director evaluates the Grant and Per Diem Program medical emergency procedures, seeks consultation with relevant subject matter experts including IntegratedEthics®, and takes action as appropriate.
Date Issued
|
Report Number
19-07682-103
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/19/2021
The VA St. Louis Health Care System Director makes certain the Chief of Staff ensures research providers take action based on stress-test results to include coordination of care and notification to primary providers as warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The VA St. Louis Health Care System Director ensures that a full retrospective review of patients enrolled, to date, in the Arm Exercise Versus Pharmacologic Stress Testing for Clinical Outcome Prediction study with positive stress tests received communication of their test result and follow-up care if indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The VA St. Louis Health Care System Director ensures that a review of Patient A’s case is completed to determine if disclosure is warranted.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/19/2021
The VA St. Louis Health Care System Director makes certain that the Institutional Review Board ensures adherence to the research study plan related to communication to the primary provider of patient enrollment in the study.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The VA St. Louis Health Care System Director ensures alignment of content for the regadenoson stress test protocols and education provided to staff and healthcare trainees.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/18/2020
The VA St. Louis Health Care System Director ensures the stress test laboratory regadenoson protocol meets VA St. Louis Health Care System Memorandum 00-34 requirements.
Date Issued
|
Report Number
19-07096-108
|
Topics: Patient Safety
● Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/14/2020
The VA Black Hills Healthcare System Director complies with Veterans Health Administration requirements that Level 1 and 2 facilities have an assistant chief of Sterile Processing Services on staff.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The VA Black Hills Healthcare System Director ensures that Sterile Processing Services leaders track changes to manufacturer’s instructions, updates standard operating procedures, retrains staff as needed, and monitors compliance with Veterans Health Administration policy.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/14/2020
The VA Black Hills Healthcare System Director ensures that Sterile Processing Services leaders maintain up-to-date staff competencies for reprocessing, and monitors compliance with Veterans Health Administration policy.
Date Issued
|
Report Number
19-08397-99
|
Topics: Financial Management
Date Issued
|
Report Number
19-07535-92
Date Issued
|
Report Number
19-05866-82
|
Topics: Contract Integrity
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The OIG recommended that the executive director of VHA Procurement establish effective and consistent quality assurance reviews, especially for contracts deemed higher risk, to ensure all closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The OIG recommended that the executive director of VHA Procurement ensure all contracting officers receive standardized training regarding the Veterans Health Administration procurement manual closeout procedures, including the correct use of closeout procedures for contracts that are awarded using Federal Acquisition Regulation part 8 and simplified acquisition procedures.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/16/2020
The OIG recommended that the executive director of VHA Procurement ensure the contract files for the 40 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and Veterans Health Administration procurement manual.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,840,219.00
Date Issued
|
Report Number
19-07090-90
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/23/2020
The Richard L. Roudebush VA Medical Center Director reviews and develops cardiology recruitment and retention processes to reach the approved staffing level.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The Richard L. Roudebush VA Medical Center Director explores the possible reasons for difficulties recruiting and retaining cardiologists and takes action to resolve identified issues.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The Richard L. Roudebush VA Medical Center Director ensures that facility staff understand the Veterans Health Administration policy regarding authorized and unauthorized patient wait lists, and monitors compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/19/2020
The Richard L. Roudebush VA Medical Center Director ensures facility managers train staff regarding the consult process and wait list policies, and monitors compliance.
Date Issued
|
Report Number
18-01275-89
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director identifies facility resources and other means for provider education and training to strengthen skills when deficiencies in care are identified during peer reviews.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures that Peer Review Committee meeting minutes document reasons for changes to peer review levels, and that changes are consistent with its review of relevant aspects of clinical care.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures review of procedures to make certain gastroenterology staff coordinate care with referring providers and provide staff training on care coordination procedures as needed.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/18/2021
The Dayton VA Medical Center Director makes certain that Community Living Center staff utilize the Situation, Background, Assessment, and Recommendation communication tool and document transfers to the Emergency Department in accordance with Dayton VA Medical Center policy.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director considers consolidating Medical Center policies related to patient transfers and transports to and from the Emergency Department into one policy to provide clear guidance to staff to effect timely transfers.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures consistent implementation of standing orders in the Emergency Department.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The Dayton VA Medical Center Director verifies policies and procedures are in place for monitoring of critically ill patients to track deterioration and need for intervention in the Emergency Department and during transport, and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/25/2021
The Dayton VA Medical Center Director ensures that handoff communication between Emergency Department providers is accurate and documented in the electronic health record during transitions in care in accordance with Dayton VA Medical Center policy, and compliance is monitored.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director ensures review of results from the revision of the Dayton VA Medical Center policy on threshold for peer review findings to trigger management reviews in order to confirm the revised policy is appropriately sensitive to identify provider practice issues that constitute patient safety concerns, and revise the policy if needed.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The Dayton VA Medical Center Director confirms all code carts in the Emergency Department are processed and secured consistent with Dayton VA Medical Center policy.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/18/2021
The Dayton VA Medical Center Director ensures Emergency Department supplies are secured and maintained consistent with Dayton VA Medical Center policy.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The Dayton VA Medical Center Director ensures continued monitoring and compliance with bar code medication administration policy in the Community Living Center.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 3/25/2021
The Dayton VA Medical Center Director reviews document management procedures for professional practice evaluations and takes actions as needed to comply with the VA Records Control Schedule.
Date Issued
|
Report Number
18-03251-88
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to General Counsel (OGC)
Closure Date: 2/18/2020
The Office of General Counsel communicates to its telework-approving supervisors that they lack authority to grant permanent exceptions to the twice-per-pay-period reporting requirement of 5 C.F.R. § 531.605(d)(1), and that in any instance in which an exception is granted pursuant to 5 C.F.R. § 531.605(d)(2) or any other applicable provision, the supervisor is obligated to periodically reassess the employee’s telework arrangement to determine whether a permanent change of official worksite is necessary.
Date Issued
|
Report Number
19-07119-80
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Determine whether public-use disability benefits questionnaires continue to be an effective means of gathering evidence to support claims for benefit entitlement and, if necessary, take steps to discontinue their use.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Update the Veterans Benefits Administration’s adjudication procedures manual to assist claims processors in determining whether public-use disability benefits questionnaires were conducted through telehealth and include specific steps on what to do if claims processors suspect that public-use disability benefits questionnaires were completed via telehealth.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Revise public-use disability benefits questionnaire forms to include a mechanism for the private provider to indicate whether the examination was completed in person or through telehealth.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 7/16/2020
Notify veterans and private providers on public-facing forums and public-use disability benefits questionnaires that telehealth examinations are not acceptable for use in making benefit entitlement determinations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 613,000.00
Date Issued
|
Report Number
18-05113-81
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Under Secretary for Health supplements the use of Community Living Center Compare with adjustment measures to better address the Community Living Center to Centers for Medicare and Medicaid Services comparison challenges for veterans, their families, and the public.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The Under Secretary for Health continues to develop specific measures that employ a more rigorous risk adjustment to better measure staffing and quality performance with respect to the Community Living Center population.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The Under Secretary for Health develops a resource that works in conjunction with other information about Community Living Centers to provide an understandable narrative for veterans, their families, and the public.
Date Issued
|
Report Number
18-05738-56
|
Topics: Claims and Fiduciary
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/4/2022
The OIG recommended the under secretary for benefits conduct a review of automatically and manually completed fiscal year 2016 drill pay adjustments that involved active duty military periods during that fiscal year, and take corrective actions as necessary.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/4/2022
The OIG recommended the under secretary for benefits conduct a review of automatically and manually completed fiscal year 2016 drill pay adjustments that involved a response to the proposal letter, and take corrective actions as necessary.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/16/2020
The OIG recommended the under secretary for benefits remind Intake Processing Center staff of their responsibilities for processing responses to drill pay proposal letters, including the appropriate actions to take when a response is received disagreeing with the proposal, and implement a plan to ensure staff compliance.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 11/6/2020
The OIG recommended the under secretary for benefits implement a plan to provide detailed training for VBA staff who process drill pay adjustments and monitor the effectiveness of the training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 56,800,000.00
Date Issued
|
Report Number
19-06435-84
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/26/2020
The VA Western Colorado Health Care System Director ensures the VA Western Colorado Health Care System Chief of Staff evaluate the management of the identified patient’s abnormal test results and provide re education to all primary care providers on their duties when alerted to abnormal blood smear results.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/26/2020
The VA Western Colorado Health Care System Director requests a conflict of interest review from the VA Office of General Counsel regarding the urologists’ ownership of the extracorporeal shock wave lithotripsy company and provides an accurate description of the alternate forms of treatment and the comparable costs associated with those treatments.
Date Issued
|
Report Number
19-06757-70
|
Topics: Claims and Appeals
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 10/16/2021
Review rating decisions made by the rating veterans service representative since being released on single-signature status, and correct any decisions found to be made in error.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/30/2020
Ensure rating decisions involving clear and unmistakable errors are signed by a quality review specialist and the veterans service center manager, or their designee.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 7/28/2020
Ensure rating veterans service representatives do not have the function to establish claims in VA’s electronic system.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 311,000.00
Date Issued
|
Report Number
19-06866-68
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The network director ensures that staff at each Veterans Integrated Service Network facility perform the required acute inpatient stay reviews and monitors staff compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The quality management officer confirms that an interdisciplinary group at each facility reviews utilization management data and monitors the group’s compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The quality management officer makes certain that staff at each facility annually complete a minimum of eight root cause analyses and monitors staff compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/18/2021
The chief medical officer ensures that facility clinical managers define criteria in advance for licensed independent practitioners’ focused professional practice evaluations and monitors clinical managers’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief medical officer confirms that facility clinical managers include service-specific criteria in ongoing professional practice evaluations for licensed independent practitioners and monitors clinical managers’ compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief medical officer confirms that ongoing professional practice evaluation results are based on evaluation by another provider with similar training and privileges and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief medical officer verifies that facilities’ executive committee of the medical staff document the decision to recommend continuing privileges for licensed independent practitioners based on ongoing professional practice evaluation results and monitors committees’ compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The chief medical officer makes certain that facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames with licensed independent practitioners for focused professional practice evaluations for cause and monitors clinical managers’ compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The deputy network director ensures a written policy establishes and maintains a Veterans Integrated Service Network-level comprehensive environment of care program.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The deputy network director makes certain that the emergency management committee conducts an annual review of the emergency operations plan, continuity of operations plan, and hazards vulnerability analysis and monitors the committee’s compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/3/2020
The deputy network director makes certain that the emergency management committee conducts, documents, and sends an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement to leadership for review and approval and monitors the committee’s compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/24/2020
The quality management officer reviews Veterans Integrated Service Network facilities’ controlled substances inspection quarterly trend reports.
Date Issued
|
Report Number
19-00054-72
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/23/2020
The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors the patient safety manager’s compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The facility director ensures that a formal process is established to review override reports and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The facility director makes certain that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The chief of staff verifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/23/2020
The chief of staff ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/15/2021
The facility director confirms that the Women’s Health Committee is comprised of the required core members and monitors committee’s compliance.
Date Issued
|
Report Number
19-06378-73
|
Topics: Patient Safety
● Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure sufficient staffing to provide gender-specific care by designated women’s health primary care providers.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director ensures steps are taken to reduce panel sizes of designated women’s health primary care providers as required by Veterans Health Administration policy.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The VA North Texas Health Care System Director reviews the Veterans Health Administration policy recommended extended appointment times for comprehensive women veterans healthcare examinations and takes action as appropriate to achieve compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure that appropriate resources, such as equipment, supplies, and space, are adequate to support comprehensive women veterans healthcare.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The VA North Texas Health Care System Director takes steps to ensure that the Women Veterans Program Manager participates in the environment of care rounds and monitors for compliance with Veterans Health Administration policy.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director evaluates clinic areas where gender specific primary care is currently provided and when planning renovations to existing areas to ensure adequate restroom access for women veterans and takes action as appropriate.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The VA North Texas Health Care System Director continues to evaluate and support staffing changes in the gynecology specialty clinic to enhance services.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/24/2022
The VA North Texas Health Care System Director ensures implementation of an effective tracking mechanism to ensure VA providers receive results for women veterans referred to care in the community and monitors for compliance with Veterans Health Administration policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/24/2022
The VA North Texas Health Care System Director verifies review of the electronic health records of women veterans referred to Care in the Community whose medical records have not been obtained and takes action if indicated.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure performance and evaluation processes provide the intended assessment of compliance with Veterans Health Administration requirements and monitors for compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director verifies that institutional disclosures are conducted for events that meet disclosure criteria and monitors for compliance with Veterans Health Administration policy.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director takes steps to ensure the required number of combined totals of root cause analyses and aggregated reviews are completed, and monitors for compliance with Veterans Health Administration policy.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 9/29/2020
The VA North Texas Health Care System Director ensures completion of root cause analyses within the required timeframes and monitors for compliance with Veterans Health Administration policy.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 7/20/2020
The VA North Texas Health Care System Director verifies that staff complete training on policy related to high-risk patient goals of care conversations for life-sustaining treatment plans and monitors for completion of training.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The VA North Texas Health Care System Director ensures staff conduct high-risk patient goals of care conversations for life-sustaining treatment plans as required and monitors for compliance with Veterans Health Administration policy.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The VA North Texas Health Care System Director takes steps to ensure provider documentation of high-risk patient goals of care and life-sustaining treatment plan in the required electronic health record template and monitors for compliance with Veterans Health Administration policy.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The VA North Texas Health Care System Director verifies capture and reporting of all codes to the resuscitation subcommittee and monitors for compliance with Veterans Health Administration policy.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The VA North Texas Health Care System Director ensures that the Critical Care Committee minutes reflect corrective action plans and follow-through to remediate concerns identified by the resuscitation subcommittee and monitors for compliance.
Date Issued
|
Report Number
18-05565-74