All Reports

Oversight and Resolution of Home Loan Defaults
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18-03979-204

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/23/2020
The under secretary for benefits implements controls to identify and address unreported monthly loan status in the upgraded VA Loan Electronic Reporting Interface system and implement compensating controls in the interim.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/24/2020
The under secretary for benefits ensures that loan servicers report when loss mitigation letters are sent and impose necessary regulatory infractions when required.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/24/2020
The under secretary for benefits ensures post-audit and adequacy of servicing reviews are compiled and trended and generate key loan servicer performance statistics.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2019
The under secretary for benefits develops a plan to implement a formal tier-ranking system following the implementation of the upgraded VA Loan Electronic Reporting Interface system.
Facility Hiring Processes and Leaders’ Responses Related to the Deficient Practice of a Radiologist at the Charles George VA Medical Center, Asheville, North Carolina
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18-05316-234

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The Charles George VA Medical Center Director verifies that facility managers adhere to Veterans Health Administration policy that outlines the credentialing and privileging process for licensed independent practitioners.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2020
The Charles George VA Medical Center Director and managers meet all requirements of state licensing boards reporting.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/19/2020
The Charles George VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting of all adverse events to the Patient Safety Manager.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The Charles George VA Medical Center Director confers with Human Resources regarding the actions taken by facility leaders and managers, related to the lack of oversight and failure to conduct credentialing and privileging per Veterans Health Administration requirements, and take administrative action(s) as necessary.
OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, FY 2019
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19-00346-241
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Topics:  Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Under Secretary for Health ensures completion of all open action plans related to recommendations from previous iterations of this report.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2020
The Under Secretary for Health identifies a plan of action that will address the underlying causes of severe occupational staffing shortages identified in this report.
Emergency Department Care of Intoxicated Patients and Those with Mental Health Conditions at the Louis Stokes Cleveland VA Medical Center, Ohio
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19-07818-242

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2020
The Louis Stokes Cleveland VA Medical Center Director defines what elements are required for a medical screening exam to deem a patient medically stable prior to transfer to the Psychiatric Assessment and Observation Center.
Comprehensive Healthcare Inspection of the North Florida/South Georgia Veterans Health System, Gainesville, Florida
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19-00010-237

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff ensures all required representatives participate in the interdisciplinary review of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain that the patient safety manager or designee includes all required components in each root cause analysis and monitors patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director ensures that the identified committee reviews all resuscitative episodes and monitors the committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The chief of staff ensures that clinical managers clearly define focused professional practice evaluation criteria in advance with providers and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2021
The chief of staff confirms that clinical managers include service/section-specific criteria in ongoing professional practice evaluations and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The chief of staff makes certain that service chiefs’ determination to recommend continuation of privileges be based in part on results of ongoing professional practice activities and monitors service chiefs’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The deputy director confirms that facility managers maintain a safe and clean environment throughout the healthcare system and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The deputy director ensures the furnishings in the intensive care units are repaired or replaced and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The deputy director makes certain that medical biohazardous waste storage rooms are secured and properly identified and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The deputy director makes certain that facility management service managers conduct weekly generator testing as required and monitors managers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain that controlled substances inspectors complete the monthly controlled substances inspections and physical inventory counts on the day initiated and that the controlled substances coordinator evaluates and maintains supporting documentation and monitors inspectors’ and coordinator’s compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director ensures controlled substances inspectors do not inspect the same area for two or more consecutive months and monitors inspectors’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain the controlled substances coordinator ensures that written and electronic controlled substance orders have been verified and monitors coordinator’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director ensures that controlled substances inspectors verify there is a corresponding sealed evidence bag containing drug(s) for each medication listed on the “Destructions File Holding Report” during monthly inspections and monitors inspectors’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director ensures that controlled substances inspectors complete pharmacy prescription pad inventories during monthly pharmacy inspections and monitors inspectors’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director ensures the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances orders during monthly area inspections and monitors inspectors’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
The facility director makes certain that controlled substances inspectors complete the verification of the twice weekly pharmacy inventory as required and monitors inspectors’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff ensures clinicians reconcile medication information and maintain accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The facility director makes certain that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The facility director confirms that the Women Veterans Health Committee reports to an executive leadership committee and monitors the committee’s compliance.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The chief of staff ensures that staff collect and track cervical cancer screening data and monitors staff compliance.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director makes certain that the emergency department has on-call social work staff available to assist with patient care and monitors staff compliance.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The facility director confirms adequate directional signage leads patients to the emergency department and monitors staff compliance.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The facility director ensures the chief of Health Information Management facilitates the timely scanning of clinical reports into patients’ electronic health records and monitors compliance.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The deputy director ensures medical equipment is evaluated per manufacturers’ recommendations and monitors compliance.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2020
The deputy director ensures that full and empty oxygen gas cylinders are physically separated and clearly labeled and monitors compliance.
Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia
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18-04679-239

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2019
The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors advisors’ compliance
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director confirms that the patient safety manager includes all required content in root cause analyses and monitors patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director makes certain the Code Blue Committee reviews each resuscitative episode under the facility’s responsibility and monitors Code Blue Committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2020
The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated criteria and time frames in advance and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
The chief of staff ensures that focused professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2020
The chief of staff makes certain that the Medical Professional Standards Committee reviews and evaluates licensed independent practitioners’ professional practice evaluations when recommending approval of privileges through the Medical Executive Council to the director and monitors committee’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2020
The chief of staff ensures that service chiefs consistently collect and review ongoing professional practice evaluation data and monitors service chiefs’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2020
The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director makes certain that the controlled substance inspectors conduct the monthly inventories of controlled substances and the controlled substances coordinator maintains supporting documentation of the completion of the monthly inventory of controlled substances and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director makes certain that controlled substances inspectors complete the pharmacy monthly controlled substances inspection inventory on the day initiated and monitors inspectors’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director makes certain that during monthly inspections, controlled substances inspectors verify that each medication listed on the “Destructions File Holding Report” is contained in a corresponding sealed evidence bag and monitors compliance of controlled substance inspection staff.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director ensures that controlled substances inspectors and coordinator carry out all responsibilities for the verification of pharmacy prescription pad counts during monthly pharmacy inspections and monitors controlled substances inspections staff compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director ensures the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of written controlled substances prescriptions during monthly area inspections and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The facility director makes certain that controlled substances inspectors and coordinator carry out responsibilities for the 72-hour pharmacy inventory checks as required and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2020
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The chief of staff ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2020
The facility director makes certain that the women veterans program manager position is full time and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2019
The chief of staff ensures the emergency department has an independent licensed mental health provider available as required for 1a facilities and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2020
The chief of staff ensures that sufficient signage assists and directs patients in locating the emergency department and monitors compliance.
Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama
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19-00057-238

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The facility director requires the patient safety manager to ensure completion of the required minimum of eight root cause analyses each fiscal year and monitors patient safety manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The facility director makes certain that the patient safety manager or designee includes all the required elements in root cause analyses and monitors patient safety manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director ensures that managers consistently implement improvement actions arising from root cause analysis activities and evaluate actions taken for sustained improvement and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The facility director ensures the patient safety manager or designee provides feedback to individuals or departments who submit patient safety incidents that result in root cause analysis and monitors patient safety manager compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2020
The chief of staff ensures ongoing professional practice evaluations utilize assessments by providers with similar training and privileges and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2020
The associate director ensures that a safe and clean environment is maintained throughout the facility and Selma VA Clinic and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2020
The associate director ensures the VA police respond to panic alarm testing in the locked mental health unit and document response time and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The associate director ensures that the comprehensive emergency management plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2020
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. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2020
The director makes certain that the chief of staff assigns a women’s health medical director or clinical champion and monitors chief of staff’s compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2021
The chief of staff confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2020
The chief of staff ensures that providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.
Alleged Poor Quality of Cancer Care at the VA Caribbean Healthcare System, San Juan, Puerto Rico
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18-01879-232

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The VA Caribbean Healthcare System Director strengthens procedures to ensure that medical oncology staff monitor patients receiving chemotherapy to assess for toxicity symptoms and patient tolerance, and the monitoring is documented in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The VA Caribbean Healthcare System Director ensures that program managers assess the need for care coordination agreements between the community living center and specialty services and, if warranted, implement the agreement(s).
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The VA Caribbean Healthcare System Director partners with community living center managers to provide education to nursing staff on the communication of patient status changes using the observation and communication tool, and procedures as outlined in VA Caribbean Healthcare System policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2020
The VA Caribbean Healthcare System Director makes certain that community living center managers conduct a review of patient care plans to confirm their accuracy, update them as necessary, and strengthen processes to prevent future omissions as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/26/2020
The VA Caribbean Healthcare System Director verifies that primary care physicians receive the education on the management of patients with prostate cancer being provided to urology and radiation oncology physicians.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2021
The VA Caribbean Healthcare System Director ensures that the findings identified by Veterans Integrated Service Network reviewers as noted in this report are addressed and resolved.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Veterans Integrated Service Network 8 Director makes certain that consistent and clear instructions are provided for all management reviews conducted concurrently by independent reviewers.
Comprehensive Healthcare Inspection of the Sheridan VA Medical Center, Wyoming
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18-04681-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The chief of staff ensures that clinical managers define and communicate expectations for focused professional practice evaluations in advance and maintain appropriate documentation of the processes, and monitors the clinical managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The chief of staff ensures ongoing professional practice evaluations include service-specific criteria and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The chief of staff makes certain that service chiefs collect and review ongoing professional practice evaluation data and that the facility’s Executive Committee of the Medical Staff reviews the data in the consideration to continue provider privileges, and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The chief of staff confirms that the solo pathologist’s ongoing professional practice evaluation includes the minimum required specialty criteria and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The associate director validates that the environment of care rounds team is trained to identify and record all environment of care deficiencies during environment of care rounds, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The facility director works with the VISN director and contracting officer to make certain that the Rock Springs VA Clinic property owners correct deficiencies and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The associate director ensures the VA police document response time to panic alarm testing at the locked inpatient mental health unit and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2021
The associate director ensures flooring that provides cushioning is installed in the mental health seclusion rooms.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The associate director validates that the facility’s emergency operations plan includes all required elements and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The associate director makes certain that monthly emergency generator testing includes documentation of dynamic load used and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The facility director makes certain that monthly reconciliation of one day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The facility director ensures that controlled substances inspectors verify controlled substances orders on a monthly basis and monitors the inspectors’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The facility director affirms that controlled substances coordinators refrain from conducting routine inspections and monitors the coordinators’ compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The facility director makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The chief of staff ensures clinicians provide and document patient/caregiver education for newly prescribed medications and monitors the clinicians’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2021
The facility director ensures the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The facility director must seek a waiver should the facility continue to operate the urgent care center 24 hours a day, seven days a week.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The facility director ensures that the urgent care center is staffed with a licensed physician and a minimum of two registered nurses at all times of operation and monitors compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The chief of staff ensures that a backup call schedule is maintained for urgent care providers and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2020
The chief of staff ensures the emergency department integration software tracking program is fully implemented for data entry and that the information is utilized for improvement and monitors compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2020
The facility director ensures appropriate signage directs patients to the urgent care center and monitors compliance.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/24/2020
The facility director ensures that equipment and supplies necessary to care for patients are readily available at all times in the urgent care center and monitors compliance.
Equipment and Supply Mismanagement at the Hampton VA Medical Center, Virginia
|
19-00260-215

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
Assign a room number and designate a custodial officer to the second-floor operating room storage location and allocate responsibility to identify inventory and update the equipment inventory listing for the appropriate medical center services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
Ensure barcodes are affixed to all storage locations and items to properly track and identify nonexpendable equipment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
Verify and update the information in the Automated Engineering Management System/Medical Equipment Reporting System to ensure all equipment in the second-floor operating room storage location is entered into the system and has accurate item status and location.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2020
Ensure Logistics Service management complies with requirements for completion of reports of survey for equipment identified as lost or stolen.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Develop and implement a process to ensure Logistics Service staff adhere to requirements for proper disposal of equipment that is no longer needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/17/2020
Ensure Logistics Service staff use the auto-generate function within the Generic Inventory Package to identify the appropriate quantities for supply orders.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2020
Require Logistics Service management to conduct monthly verifications of the Generic Inventory Package reports to ensure staff use of the system for the receipt and distribution of supplies.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
Ensure barcodes are affixed to all storage locations, storage shelves, and bins to properly track and identify expendable supplies.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2020
Ensure Logistics Service management monitors and reviews the weekly verification of expired inventory and ensures log sheets are properly annotated and maintained.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
Ensure a staffing plan is implemented to continue filling vacancies based on clinical and administrative workload and includes contingencies for any positions with high turnover rates.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
Ensure national requirements for ordering procedures are strictly followed to ensure requestor, approving authority, and receiver for all purchases are not the same individual.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
Implement a process to sufficiently and timely address and correct deficiencies identified during the Veterans Integrated Service Network quality control reviews.
Construction Project Management at the Ralph H. Johnson VA Medical Center in Charleston, South Carolina
|
18-01944-214

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2019
The OIG recommended the director of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina, ensure a process is established requiring that the Veterans Integrated Service Network 7 capital asset manager be informed, prior to construction contact awards, if construction is not planned to start within 150 days after contract awards, so that prudent decisions can be made in a timely manner regarding project funds.
Workload Management Challenges Identified at the Salt Lake City, Utah, Fiduciary Hub
|
19-06565-217

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
The Director of the Salt Lake City Regional Office ensures the Fiduciary Hub workload management plan establishes timeliness goals for the various action mail tasks.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2020
The Director of the Salt Lake City Regional Office makes certain fiduciary hub managers measure performance and monitor adherence to timeliness goals for action mail tasks once established.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
The Director of the Salt Lake City Regional Office establishes a requirement within the Fiduciary Hub workload management plan for routinely reviewing and resolving duplicate action mail tasks.
Leadership Failures Related to Training, Performance, and Productivity Deficits of a Provider at a Veterans Integrated Service Network 10 Medical Facility
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19-06429-227

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2020
The Veteran Integrated Service Network 10 Medical Facility Director ensures the Credentialing and Privileging process for primary source verification of foreign education is performed and documented in accordance with Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2020
The Veteran Integrated Service Network 10 Medical Facility Director ensures that the Credentialing and Privileging process for verifying and accepting professional references meets sufficiency standards in accordance with Veterans Health Administration guidance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2020
The Veteran Integrated Service Network 10 Medical Facility Director ensures that the Focused Professional Practice Evaluation process used to determine technical competence and skills meets Veterans Health Administration requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
The Veteran Integrated Service Network 10 Director evaluates whether the decision to reappoint the surgeon referenced in this report was improperly influenced by the Chief of Staff’s resolve to retain the services of the surgeon’s spouse in a sub-specialty position, and take action, if indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
The Veteran Integrated Service Network 10 Medical Facility Director coordinates with Veterans Integrated Service Network 10 or other resources to assist and support sole providers with performance deficits.
Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma
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18-06510-222

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The chief of staff makes certain that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff makes certain that all focused professional practice evaluations include clearly defined time limitations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff confirms that clinical managers share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors clinical managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The associate director confirms that unit supervisors remove clean and sterile packaged items from shipping cartons and corrugated boxes prior to stowing in clean or sterile storage areas and monitors unit supervisors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director ensures that the military sexual trauma coordinator tracks and monitors the screening, referral, and treatment services provided to veterans and monitors coordinator’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the risks/benefits, potential interactions, and side effects of newly prescribed medications and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff ensures clinicians maintain and communicate accurate patient medication information in patients’ electronic health record and reconcile medications and monitors clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2021
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director makes certain that the Women Veterans Health Committee reports at least quarterly to the Medical Executive Committee.
State Prescription Drug Monitoring Programs Need Increased Use and Oversight
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18-02830-164

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2021
Develop national processes to oversee medical facility compliance with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, and coordinate the possible automated information technology solutions and inter-office and -disciplinary communications necessary to improve prescription drug monitoring program monitoring and usage in Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2021
Update the Pain Management and Opioid Safety training course to specifically address VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, query requirements and recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
Ensure VA clinicians who prescribe opioids take the Pain Management and Opioid Safety training once, with annual refresher training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Add an addendum to VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, that references the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain and ensure VA clinicians are educated and receive annual training on the Clinical Practice Guideline, to include the Centers for Disease Control and Prevention’s recommended frequency for prescription drug monitoring program queries based on the patients’ risk factors.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Direct Veterans Integrated Service Networks and their VA medical facilities to ensure local policies are consistent with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/11/2021
Develop automated information technology solutions to facilitate clinicians’ access toprescription drug monitoring program query information and reinforce the need tocomplete minimum annual VA-required prescription drug monitoring program queries.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2020
Ensure non-VA care clinicians are in good standing and have a current state medical license that requires adherence to their state’s prescription drug monitoring program query requirements; adhere to the Veterans Affairs Opioid Safety Initiative Guidelines, including guidelines for prescription drug monitoring program queries; and are monitored to ensure appropriate corrective actions are taken if their prescribing practices are found to be inconsistent with VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Ensure Veterans Integrated Service Networks implement an effective prescription drug monitoring program oversight process that includes the review of compliance rates with medical facility directors.
Alleged Care Delays and Inadequate Instrument Precleaning at the New Mexico VA Health Care System, Albuquerque
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18-03526-230

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director ensures that patients denied a Veterans Choice Program referral are informed of their rights to appeal, that facility policy is consistent with Veterans Health Administration requirements, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director verifies that the Ophthalmology and Optometry Departments’ consult management and scheduling practices are consistent with Veterans Health Administration patient indicated date timeframe requirements, incorporates patient preference, and includes receiving provider review of consults, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director makes certain the Ophthalmology and Optometry Departments’ clinical and administrative staff receive training regarding Veterans Health Administration requirements of consult management and scheduling practices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director reviews the Ophthalmology Department’s eye cataract intake surgery scheduling practice and ensures that overall timeliness is consistent with Veterans Health Administration directives, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The New Mexico VA Health Care System Director conducts a timeliness review of the authorization process for non-VA Care routine eye appointments, including diabetic eye examinations, and implement action plans if the process fails to adhere to Veterans Health Administration directives.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director ensures the Gastroenterology Department’s consult management practices are consistent with Veterans Health Administration scheduling requirements for patient indicated dates, and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director establishes a routine review of Gastroenterology Department consult performance measures and a method to monitor identified deficiencies consistent with Veterans Health Administration requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2020
The New Mexico VA Health Care System Director evaluates whether test results within the past 12 months, ordered by the Gastroenterology Department were communicated to patients according to Veterans Healthcare Administration and facility policy, and takes action as necessary based on the results of the evaluation.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director reviews facility policy for the ordering and reporting of test results to be in alignment with Veterans Health Administration directives and completes revisions, if needed.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director ensures that Gastroenterology Department-ordered test results are communicated timely in accordance with Veterans Health Administration and facility policy and the timeliness is monitored through the ongoing peer review process as required by facility policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The New Mexico VA Health Care System Director ensures that the Gastroenterology Department Service Chief develop a process for delegating responsibility and accountability for test results and follow-up when multiple providers are involved, and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director ensures documented endoscope precleaning training for Gastroenterology Fellows, and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director verifies that documentation of endoscope precleaning competencies for Gastroenterology Fellows is consistent with Veterans Health Administration requirements.
Boston, Massachusetts, VA Regional Office Supervisor Incorrectly Processed Work Items
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19-07350-192

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/18/2020
The director of the Boston VA Regional Office reviews and corrects all work items that were cancelled or cleared by the supervisor that are likely to result in adjustments to recipients’ benefit payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2019
The director of the Boston VA Regional Office confers with regional counsel to determine the appropriate administrative action to take, if any, against the supervisor.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2020
The director of the Boston VA Regional Office implements a plan to ensure internal controls for assessing the quality of claims processed by supervisors.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 84,400.00
Quality of Care and Patient Safety Concerns on the Acute Behavioral Health Unit at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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18-00777-224

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that providers understand the importance of monitoring for cardiac changes, drug-drug interactions, and signs of oversedation when initiating patients on methadone.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director monitors that providers and clinical staff effectively and directly communicate with one another when providing complex patient care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director confirms that the issue brief submitted on the identified patient contains accurate information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director reviews the root cause analysis related to the identified patient to determine if the team composition compromised the integrity of the root cause analysis and take appropriate action if necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that root cause analysis team compositions include appropriate staff and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director considers Peer Review for Quality Management for the additional two providers identified in this report.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that Unit 7E staff are knowledgeable of the observation policy, and nursing leaders are monitoring staff compliance when assigned rounding responsibilities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director completes actions initiated or taken to resolve identified deficiencies that contributed to the events discussed in this report, and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director certifies that providers receive ongoing education on the required elements of a signed written consent prior to the initiation of methadone and ensures that providers comply with VA policy and monitors for compliance.
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