Date Issued
|
Report Number
19-08728-166
|
Topics: Education and Loan Guaranty
All Reports
Date Issued
|
Report Number
18-06292-117
|
Topics: Community Care
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
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
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
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
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.
Date Issued
|
Report Number
19-06870-175
|
Topics: Patient Safety
● Medical Staff Privileging Credentialing
● Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
19-07827-182
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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.
Date Issued
|
Report Number
19-05798-107
|
Topics: VA Police
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 4/14/2022
The OIG recommends that the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Under Secretary for Health evaluate the appropriateness of having the Law Enforcement Training Center serve as the manager of the records management systems for VA police.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/21/2021
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Assistant Secretary for Information and Technology, as well as the Under Secretary for Health establish a working group of subject matter experts and evaluate whether the Report Exec system meets the needs of VA police. The group should evaluate if the system meets police needs and whether contract requirements have been fully achieved, then develop a strategy to ensure that police units at all medical facilities have a reliably performing records management system to report and track activities.
No. 3
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 10/22/2021
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Principal executive Director for the Office of Acquisition, Logistics and Construction; the Assistant Secretary for Information and Technology; and the Under Secretary for Health develop and implement a plan describing how, when, and to whom information about issues for the police records management system will be disseminated and resolved.
No. 4
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 4/14/2022
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness, in consultation with the Under Secretary for Health, update security and law enforcement program procedures to ensure they meet information management needs and requirements.
No. 5
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 12/18/2020
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the Assistant Secretary for Information and Technology and Principal Executive Director for the Office of Acquisition, Logistics and Construction initiate an agreement with the contractor to ensure information security measures are in place for the VA police records that were stored on the contractor’s server to prevent unauthorized use and their proper disposal.
No. 6
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 10/22/2021
The OIG recommended the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness in consultation with the General Counsel and the Assistant Secretary for Office of Accountability and Whistleblower Protection determine the appropriate administrative action to take, if any, against personnel involved in bypassing the requirement that the Report Exec system be hosted at the Austin Information Technology Center and the VA information security process be completed before operation.
No. 7
to Information and Technology (OIT)
Closure Date: 10/20/2020
The OIG recommended the Assistant Secretary for Information and Technology in coordination with the Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness ensure an Information Security Officer is consistently responsible for the Report Exec system and properly notified.
Date Issued
|
Report Number
18-00711-106
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The VA Tennessee Valley Healthcare System (TVHS) director ensures the Middle Tennessee Research Institute’s Board of directors establishes procedures to verify adequate supporting documentation prior to approval of expenditures.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The OIG recommended that the VA Tennessee Valley Healthcare System (TVHS) director ensure the MTRI board of directors establishes procedures that require staff to verify supporting documentation before approving expenditures.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The OIG also recommended that the system director should establish procedures to ensure the R&D Budget Office supervisor conducts required periodic reviews of VA-affiliated nonprofit corporation invoices that staff have authorized for payment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 1,900,000.00
Date Issued
|
Report Number
18-00711-141
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/13/2021
The San Francisco VA Healthcare System director establishes procedures to ensure the Research and Development Budget Office staff 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. 2
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The San Francisco VA Healthcare System director establishes procedures to ensure 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: $ 25,940,000.00
Date Issued
|
Report Number
19-06391-119
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Coatesville VA Medical Center Director reviews and monitors staff compliance with the Community Living Center required nursing processes and documentation for medication administration, pain management assessments, and care plans.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Coatesville VA Medical Center Director examines Community Living Center nursing processes and ensures that required documentation for fall prevention assessments, which include measures such as bed positions, call bell access, and post-fall assessments, is completed and monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Coatesville VA Medical Center Director reviews and monitors staff compliance with Community Living Center call bell processes and practices.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/9/2021
The Coatesville VA Medical Center Director evaluates Community Living Center wound prevention processes and ensures that required wound documentation, including the measurement of patient weights and maintenance of skin integrity, is completed and monitored for compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Coatesville VA Medical Center Director ensures that the newly developed Community Living Center hourly rounding form and process is approved in accordance with the facility’s standard operating procedure and aligns with the facility’s rounding policies, and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/11/2020
The Coatesville VA Medical Center Director makes sure that the fact-finding review process includes tracking and documenting issues through resolution and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Coatesville VA Medical Center Director ensures that the Executive Leadership Board and the Geriatric and Extended Care Executive Council review, document, and track identified facility issues and, for the Executive Leadership Board, recommendations through resolution.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Coatesville VA Medical Center Director reviews and monitors the maintenance and functionality of essential safety equipment on Community Living Center units.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/11/2020
The Coatesville VA Medical Center Director updates the facility staffing methodology policy and staffing methodology calculations to comply with current Veterans Health Administration staffing methodology requirements.
Date Issued
|
Report Number
19-08857-171
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/25/2021
The VA Maryland Health Care System Director conducts a comprehensive evaluation of the organizational health to include staff reporting of concerns and employee satisfaction at the Loch Raven Community Living Center, develops an action plan for improvement, and monitors progress.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The VA Maryland Health Care System Director reviews current laboratory specimen handling procedures at the Loch Raven Community Living Center and implements an action plan to address identified deficiencies.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The VA Maryland Health Care System Director ensures that concerns reported to Pathology &Laboratory Medicine Service are investigated and that action plans are instituted as needed.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The VA Maryland Health Care System Director ensures Pathology & Laboratory Medicine Service staff notifies providers of critical laboratory results, documents in accordance with policy, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/9/2021
The VA Maryland Health Care System Director reviews the current process for medication delivery, to include the effectiveness of recently initiated actions as described in the report, from the Baltimore VA Medical Center pharmacy to the Loch Raven Community Living Center and implements an action plan to address identified vulnerabilities.
Date Issued
|
Report Number
19-06249-94
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/28/2021
The OIG recommended the under secretary for benefits correct disability compensation benefits for the veterans identified in the sample whose benefits were not adjusted or were incorrectly adjusted.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits develop and implement a plan to ensure all VA regional offices generate and process the weekly Admission Report for Service Connected Veterans and maintain coordinators’ logs to complete required benefit adjustments.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits continue to develop and implement a plan to nationally generate and process the Admission Report for Service Connected Veterans.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2020
The OIG recommended the under secretary for benefits determine if a statutory or regulatory change is required to ensure lawful, consistent, and timely processing of benefits for veterans entitled to temporary increases of benefits to 100 percent.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 11/17/2020
The OIG recommended the under secretary for benefits develop and implement a plan to ensure staff receive refresher training when needed to properly process temporary disability compensation benefit adjustments for veterans hospitalized for more than 21 days that includes monitoring the effectiveness of the training.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 8/6/2021
The OIG recommended the under secretary for benefits develop a plan to determine which veterans required adjustment of compensation benefits for hospitalization for a service connected condition, using the Admission Report for Service Connected Veterans for fiscal years 2018 and 2019, and make the required adjustments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 40,000,000.00
Date Issued
|
Report Number
20-00417-170
|
Topics: Purchase Cards
Date Issued
|
Report Number
18-04800-122
|
Topics: Information Technology and Security
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices develop and implement policy to support the Federal Information Technology Acquisition Reform Act delegation process and submit a Chief Information Officer Assignment Plan for the Office of Management and Budget’s review and approval.
No. 2
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices establish internal controls sufficient to ensure the Chief Information Officer or the appropriate delegate reviews and approves all information technology acquisitions, regardless of appropriation, and implement improved VA policies and procedures to reflect these business processes.
No. 3
to Information and Technology (OIT)
Closure Date: 6/9/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices modify all VA policy and guidance regarding implementation of Federal Information Technology Acquisition Reform Act requirements to provide clear and consistent Information Technology acquisition processes across the department.
No. 4
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices develop and implement agency wide information technology acquisition awareness and training programs to improve VA employees’ understanding of Federal Information Technology Acquisition Reform Act requirements and the Chief Information Officer’s authority to review and approval all information technology acquisitions.
No. 5
to Information and Technology (OIT)
Closure Date: 2/6/2023
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices revise VA Directive 6008 to clarify the Chief Information Officer’s authority and roles in the planning, programming, budgeting, and execution of all information technology resources.
No. 6
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices develop and implement policies and procedures across all VA administration and staff offices to specifically identify and separate information resources from non-IT resources, regardless of funding appropriation.
No. 7
to Information and Technology (OIT)
Closure Date: 1/20/2022
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices establish policies and procedures for all VA administration and staff offices to work with the Chief Information Officer for planning, programming, budgeting, and execution of all information technology resources and to manage VA’s overall information technology portfolio with resources that effectively achieve program and business objectives.
No. 8
to Information and Technology (OIT)
Closure Date: 1/20/2022
The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices establish and implement department-level information technology governance and oversight processes to ensure that the Chief Information Officer is a member of VA governance boards that inform decisions on all information technology resources across the agency, regardless of funding appropriation.
No. 9
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the VA Assistant Secretary for Information and Technology fully develop and implement the Office of Information and Technology governance framework to ensure Federal Information Technology Acquisition Reform Act requirements are met.
No. 10
to Information and Technology (OIT)
Closure Date: 12/14/2020
The OIG recommends the VA Assistant Secretary for Information and Technology fully implement the functionality of the Office of Strategic Planning and Analysis to ensure Federal Information Technology Acquisition Reform Act compliance for information technology strategic planning.
Date Issued
|
Report Number
19-07482-91
|
Topics: Maintenance and Construction
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/1/2020
Develop an oversight process that Northport VA Medical Center leaders can rely on to effectively develop, implement, and execute the master plan to reduce the footprint of the medical center and better manage the needs of its aging infrastructure.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/1/2020
Ensure the Northport VA Medical Center director defines a timeline for executing the master plan and communicates the objectives to stakeholders to (1) instill consistency between the master and the strategic capital investment plans and (2) execute the master plan in accordance with agreed upon milestones and available resources.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/1/2020
Make certain the Northport VA Medical Center director develops processes and procedures for submitting work orders, including making notifications when work orders are assigned and reviewing work orders for accuracy and consistency, to ensure the medical center’s engineering service is in the best position to prioritize work and manage its resources.
Date Issued
|
Report Number
20-00541-149
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 12/8/2020
The assistant secretary for human resources and administration/ operations, security, and preparedness should ensure VA time to hire percentages are reported using the Office of Personnel Management’s target as required by Section 505(a)(1)(D) of the MISSION Act.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/5/2021
The assistant secretary for human resources and administration/ operations, security, and preparedness should confer with the VA Office of General Counsel to ensure that changes to the reporting methodology comply with Section 505 of the MISSION Act.
Date Issued
|
Report Number
19-07091-159
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The VA Northeast Ohio Healthcare System Director conducts a full review of the patient’s care, including electrocardiograms and methadone initiation, and considers whether an institutional disclosure is warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/9/2021
The VA Northeast Ohio Healthcare System Director ensures that electrocardiograms are completed prior to and during methadone treatment in accordance with Veterans Health Administration Pharmacy Benefits Management Services recommendations.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/15/2020
The VA Northeast Ohio Healthcare System Director ensures that domiciliary leaders implement a process to monitor the integrity of Volunteers of America staff documentation including health and safety rounding sheets and additional documentation directly pertaining to patients’ health, safety, and security.
No. 4
to Asset Enterprise Management (OAEM)
Closure Date: 6/11/2020
The VA Office of Asset Enterprise Management Director ensures that the Residential Services Agreement includes references to the Services Provider Contract between CGA LSVA Residential, LLC and Volunteers of America.
No. 5
to Asset Enterprise Management (OAEM)
Closure Date: 6/11/2020
The VA Office of Asset Enterprise Management Director, in consultation with the VA Office of General Counsel, determines if the Residential Services Agreement and the new term agreement needs to be reformed, or whether new contracts should be executed that clearly define the rights and responsibilities of all parties with respect to domiciliary services.
Date Issued
|
Report Number
19-08256-124
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures that ordering providers review, acknowledge, and document an action plan for abnormal laboratory results.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director considers initiating an institutional disclosure for the failure of primary care provider 1’s clinical action and follow-up for Patient A’s abnormal test results and takes necessary actions.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/25/2024
The Fayetteville VA Medical Center Director ensures that facility Community Care staff process Community Care consults according to the Veterans Health Administration policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director conducts a comprehensive review of Patient A’s and Patient B’s episode of care and takes action as indicated.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Fayetteville VA Medical Center Director evaluates the facility’s treating capabilities, delineates the medical conditions appropriate for admission, and updates the Policy for Admission/Discharge/Care of Patients to Intensive Care Unit.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/26/2021
The Fayetteville VA Medical Center Director conducts an analysis of the inter-facility transfer process for patients in emergency situations, and develops and implements strategies and actions for improvement.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director updates the Patient Transfer Coordination policy to include the improvements from the transfer process analysis.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director makes certain that facility staff are trained on the updated Patient Transfer Coordination policy and emergency inter-facility transfer process for inpatients and monitors the process, including timeliness of transfers.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director reviews Patient B’s emergency medical services’ 911 call cancellation, considers initiating institutional disclosure, and takes appropriate action as indicated.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures the Critical Care Committee thoroughly evaluates code blue events, identifies related performance and system issues, makes recommendations, and ensures actions are implemented.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/8/2020
The Fayetteville VA Medical Center Director makes certain that solo practitioners have the privilege-specific competency components of their focused and ongoing professional practice evaluations performed by another provider with similar training and privileges and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Fayetteville VA Medical Center Director ensures inter-facility patient data is collected, analyzed and incorporated into the facility’s quality management program.
Date Issued
|
Report Number
19-09563-142
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Executive in Charge, Veterans Health Administration, implement appropriate IPERA testing procedures to ensure evidence is sufficient to verify that services were received for the Purchased Long-Term Services and Supports program.
Date Issued
|
Report Number
19-08296-118
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director ensures compliance with requirements outlined in Veterans Health Administration and Charlie Norwood VA Medical Center policy memorandums for the prevention and management of pressure injuries, including nursing documentation requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director ensures Critical Care Unit nursing staff receive ongoing training to manage patients at risk for developing pressure injuries.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director evaluates tele-ICU services, and makes changes as needed to ensure cardiac-monitored patients receive safe care.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Charlie Norwood VA Medical Center Director ensures that a review to evaluate the circumstances related to Patient 8’s respiratory care is conducted and takes action as indicated.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director reviews current practices related to sitter availability when a physician orders a 1:1 sitter for Critical Care Unit patients and takes action as indicated.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/1/2021
The Charlie Norwood VA Medical Center Director reviews current practices related to Critical Care Unit nursing staff assignments and takes action as indicated to support safe patient care when intravenous medications that require frequent dose adjustments are prescribed.
Date Issued
|
Report Number
18-05350-135
|
Topics: Patient Safety
● Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/2/2021
The Under Secretary for Health adopts the National Radiology Program Office established guidelines and confers with the National Radiology Program Office to develop and incorporate a risk stratification methodology of the random sample of imaging modalities reviewed, to better inform radiologists’ professional practice evaluations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Veterans Integrated Service Network Director provides continued oversight of the National Teleradiology Program expanded review results, ensures an appropriate response from VA Illiana Health Care System, and takes actions, as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director verifies that appropriate patient follow-up occurs, disclosures are conducted for events that meet disclosure criteria, and compliance with Veterans Health Administration policy is monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director ensures the Radiology Service follows VA Illiana Health Care System policy to develop and implement a quality assurance and performance plan and monitors for compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director considers following the National Guidelines for Radiology Professional Competency for radiologist competency reviews.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The VA Illiana Health Care System Director evaluates the final findings of the National Teleradiology Program review to determine what additional steps are required, including large-scale disclosure and reporting to outside agencies.
Date Issued
|
Report Number
18-06074-123
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Under Secretary for Health ensures that the planning and implementation of the new electronic health record includes a process for addenda insertion, deletion, and consistent formatting for radiology reports.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/2/2020
The Under Secretary for Health reviews Veterans Health Administration policy related to management of health information in the electronic health record, evaluates the circumstances that led to the Division Manager’s decision to direct the deletion of a completed and verified imaging report, and takes action, as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director ensures a review of the radiology report for the patient with conflicting imaging study results and confirms that the most accurate impression is evident in electronic health record.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/11/2020
The Veterans Integrated Service Network Director reviews access, management, and the Veterans Integrated Service Network oversight of the Clement J. Zablocki VA Medical Center picture archiving and communication system practices, and takes action to remedy issues identified during the review, as indicated.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director reviews the oversight and management of the Medical Imaging Service, confers with human resources, makes recommendations for improvement as indicated, and monitors progress.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director completes an evaluation of the Medical Imaging Service’s culture, morale, and team cohesion, develops an action plan for improvement, and monitors progress.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Clement J. Zablocki VA Medical Center Director evaluates the need for Medical Imaging Service staff to receive training on workplace intimidation and the process for employee reporting of concerns, and takes actions, as indicated.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/6/2020
The Veterans Integrated Service Network Director makes certain that future hotline case referrals are investigated in accordance with Veterans Affairs policy related to Office of Inspector General Hotline complaint referrals, and provides oversight of facility responses.