All Reports

Medication Management, Dispensing, and Administration Deficiencies at the VA Maryland Health Care System, Perry Point, Maryland
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17-05742-66

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Veterans Integrated Service Network Director ensures evaluation of inaccuracies and risks involved with use of bulk bottles of controlled liquid solutions, takes actions as needed to reduce risks, and monitors effectiveness of actions taken.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/12/2019
The VA Maryland Health Care System Director ensures the interdisciplinary review of unit dose and multi-dose oxycodone solution dispensing and administration, takes actions as appropriate, and monitors effectiveness of actions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2019
The VA Maryland Health Care System Director consults with the Office of Chief Counsel regarding whether an institutional disclosure is appropriate for this patient’s death and takes actions as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2019
The VA Maryland Health Care System Director conducts a quality review of the patient’s death and takes actions as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2019
The VA Maryland Health Care System Director ensures that nursing staff follow facility policy in the hiring of nurses.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The VA Maryland Health Care System Director ensures evaluation and revision as needed of facility nurse competency processes on the hospice unit for high-alert medications and monitors effectiveness of actions taken.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2020
The VA Maryland Health Care System Director evaluates the care provided to other patients by the nurse who administered the potential overdose for other possible practice issues.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2019
The VA Maryland Health Care System Director ensures evaluation by nursing leaders to determine the need for reporting the nurse who administered the potential overdose to the State Licensing Board and takes steps as appropriate.
Lost Opportunities for Efficiencies and Savings During Data Center Consolidation
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16-04396-44

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/30/2019
The Assistant Secretary for Information and Technology consults with the Office of Management and Budget for additional guidance on determining whether servers the Office of Information Technology excluded from inventories were subject to the Data Center Optimization Initiative guidance in its June 2017 policy memo, Data Center Development Freeze.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/1/2019
The Assistant Secretary for Information and Technology ensures the facility Chief Information Officers effectively communicate Data Center Optimization Initiative requirements to all staff responsible for VA data centers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/1/2019
The Assistant Secretary for Information and Technology develops a mechanism for validating the accuracy and completeness of reported data center information to the Office of Information and Technology National Data Center Program team.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/30/2019
The Assistant Secretary for Information and Technology establishes a process to facilitate a VA-wide inventory of data centers, including those outside the direct control and ownership of the Office of Information Technology.
No. 5
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 1/30/2019
The Assistant Secretary for Information and Technology ensures VA’s Data Center Optimization Initiative strategic plan is complete and includes a timeline for achieving OMB’s cost savings targets, data center closures targets, and optimization performance metrics for energy metering and power usage effectiveness.
Falsification of Blood Pressure Readings at the Danville Community Based Outpatient Clinic, Salem, VA
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18-05410-62

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2019
The Salem VA Medical Center Director ensures that patients impacted by blood pressurefalsifications are evaluated and receive follow-up as clinically indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2019
The Salem VA Medical Center Director develops processes to ensure the integrity of VeteransHealth Administration Support Service Center data that supports performance metrics.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2019
The Salem VA Medical Center Director directs the development of policies and proceduresthat ensure compliance with clinical quality reporting requirements as outlined in the Danvillecommunity based outpatient clinic contract.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2019
The Salem VA Medical Center Director evaluates the adequacy of the Chief of Staff’s andChief of Primary Care’s responsiveness to the VA Office of Inspector General’s concerns andtakes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2019
The Salem VA Medical Center Director ensures the Contracting Officer’s Representativereceives the necessary training to fulfill all required functions and oversight responsibilities.
Comprehensive Healthcare Inspection Program Review of the Washington DC VA Medical Center
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17-01757-50

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Facility Director ensures that recommended actions from peer reviews and root cause analyses are implemented and monitored for improvement.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Chief of Staff ensures that assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors the staff’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Chief of Staff ensures an interdisciplinary Facility group reviews utilization management data and monitors the group’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Facility Director ensures that the Patient Safety Manager provides feedback of root cause analysis results to the reporting individuals or departments and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Chief of Staff ensures that Focused and Ongoing Professional Practice Evaluations are completed, and that the Professional Standards Board reviews these evaluations in considering whether to continue provider privileges, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/25/2021
The Associate Director ensures that safety and infection prevention processes are in place at construction sites and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The Associate Director for Patient Care Services ensures that nursing staff dispose of expired or unsealed supplies and monitors the staff’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
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: 1/6/2020
The Associate Director ensures all applicable equipment is inspected and identified as safe for patient use and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Associate Director ensures the mental health seclusion room flooring provides cushioning.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Associate Director ensures the furniture in the mental health seclusion room is limited to an appropriate style bed and monitors for compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2021
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are addressed or corrected and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2019
The Facility Director ensures that the duties of the Controlled Substance Coordinator and Alternate Controlled Substance Coordinator are included in the employees’ position description or functional statement.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The Facility Director ensures that a reconciliation of controlled substance return to pharmacy stock is performed during controlled substance inspections and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Chief of Staff ensures that the geriatric evaluation performance improvement activities are reviewed by the appropriate leadership board and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Associate Director for Patient Care Services ensures that all registered nurses involved in the insertion and/or management of central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2019
The Facility Director ensures the Chief of Health Information Management facilitate the timely scanning of clinical reports into the electronic health record and monitors compliance.
Alleged Clinical and Administrative Concerns Involving a Wound Care Provider in Veterans Integrated Service Network 21
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18-05264-58

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/21/2019
The System Director ensures completion of evaluations of Patients B and C to determine whether opportunities for more timely diagnosis of deep vein thrombosis existed, and takes action if indicated.
Mismanagement of the VA Executive Protection Division
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17-03499-20

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/21/2020
The Acting Assistant Secretary for Human Resources and Administration ensures that the VA Police Service publishes written operational policies and procedures designed to regulate essential functions of the Executive Protection Division, including threat assessment processes, motorcade operations, security drills, equipment maintenance, use of personal protective gear, and other topics deemed appropriate after consultation with executive protection experts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/10/2021
The Acting Assistant Secretary for Human Resources and Administration makes certain that an adequate threat assessment is developed and kept current for each principal secured by the Executive Protection Division.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/20/2019
The Acting Assistant Secretary for Human Resources and Administration, along with the Director of the Office of Security and Law Enforcement and the Director of Police Service, reviews the U.S. Secret Service recommendation made to VA in April 2017 about shift scheduling and either implements the recommendation or thoroughly documents the reasons for non-implementation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/21/2020
The Acting Assistant Secretary for Human Resources and Administration confers with the VA Offices of General Counsel and Accountability and Whistleblower Protection to ensure that bills of collection are issued to agents identified as receiving improper payments of overtime or travel reimbursement and to determine the appropriate administrative action to take, if any, against agents and supervisors who submitted or approved falsified time cards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/16/2020
The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against personnel involved with the nonsecure transmission of the former VA Secretary’s anticipated movements to individuals external to VA who had no need to know.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/16/2020
The Acting Assistant Secretary for Human Resources and Administration ensures that the Executive Protection Division institutes procedures to report and appropriately address security lapses, such as those described in this report, and holds agents accountable for individual conduct that contributes to such lapses.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration establishes written procedures for documenting the review and approval of employee overtime within the Executive Protection Division and ensures compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration assesses and takes remedial action, if necessary, to make certain that Executive Protection Division staff use parking and transit benefits in accordance with VA policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 9/27/2021
The Acting Assistant Secretary for Human Resources and Administration confers with the Offices of General Counsel and Accountability and Whistleblower Protection to determine whether any agents inappropriately accepted transit benefits while using VA parking spaces, and if so, determine the appropriate administrative action to take, if any.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration works with the Offices of General Counsel and Accountability and Whistleblower Protection to institute procedures for an ombudsman or similar function that will enable the Executive Protection Division agents to address management disputes without needing to involve the VA Secretary.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 1/16/2020
The Acting Assistant Secretary for Human Resources and Administration consults with the Office of General Counsel to confirm that the Executive Protection Division and the Office of Secretary have written policies and procedures reasonably designed to ensure that the principal under protection receives a thorough orientation to the appropriate uses of the Division’s services.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/10/2021
The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to provide adequate mechanisms and training for all staff within the Office of Operations, Security, and Preparedness, including the Executive Protection Division, that ensure allegations of perceived misconduct by the VA Secretary can be appropriately addressed without the threat of retaliation.
Concerns Related to the Management of a Patient’s Medication at Three VA Medical Centers and Inaccurate Response to a Congressional Inquiry at the VA Illiana Health Care System, Danville, Illinois
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18-02056-54

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Orlando VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Orlando VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of electrocardiogram test results and follow-up as clinically indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The Richard L. Roudebush VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The Richard L. Roudebush VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of medication blood level test results and follow-up as clinically indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The VA Illiana Health Care System Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2019
The VA Illiana Health Care System Director strengthens processes for effective clinical consultation and follow-up between mental health and collaborating primary care providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The VA Illiana Health Care System Director strengthens the processes for congressional inquiry response to ensure response timeliness, clinical information accuracy, and records retention, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/11/2019
The VA Illiana Health Care System Director evaluates staff actions and approval processes in the preparation of the letter to Senator Donnelly, and takes appropriate administrative action, if indicated.
Comprehensive Healthcare Inspection Program Review of the Marion VA Medical Center, Illinois
|
18-01155-48

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Chief of Staff ensures service chiefs collect Ongoing Professional Practice Evaluation data utilizing assessments 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: 6/12/2019
The Associate Director ensures Police Service regularly tests panic alarm testing and addresses identified deficiencies at the Harrisburg Community Based Outpatient Clinic and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The Associate Director ensures that the Emergency Operations Plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Facility Director ensures controlled substances inspectors verify a corresponding sealed evidence bag containing drug(s) for each medication held for destruction at the Evansville Health Care Center and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA New Jersey Health Care System, East Orange, New Jersey
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18-01164-42

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Chief of Staff ensures that clinical managers initiate and document Focused Professional Practice Evaluations that include provider- and service-specific criteria for the determination of providers’ privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Chief of Staff ensures that Ongoing Professional Practice Evaluations include service-specific criteria and are completed by a provider with similar training and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2019
The Chief of Staff ensures that the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluations in the consideration to grant provider privileges and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Associate Director–Lyons Campus ensures that managers store clean and dirty medical equipment separately and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Associate Director–Lyons Campus ensures that Public Safety Service documents the response times when testing panic alarms and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2019
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the San Francisco VA Health Care System, California
|
18-01153-43

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2019
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Chief of Staff ensures an interdisciplinary Facility group reviews utilization management data and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2019
The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2019
The Chief of Staff ensures service chiefs present the results of completed Focused Professional Practice Evaluations to the Medical Executive Committee to recommend continuing the initially granted privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Associate Director ensures that Facility managers maintain a clean and safe environment throughout the Facility and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Associate Director ensures that all staff properly safeguard patient health information and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2019
The Associate Director ensures the VA Police document response times to panic alarm testing in the locked mental health unit and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2019
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. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Surveys are addressed and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2019
The Facility Director ensures that controlled substances inspectors verify written or electronic controlled substance orders during monthly area inspections and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2019
The Facility Director ensures that controlled substance inspectors complete routine monthly controlled substance inspections and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Facility Director ensures that geriatric evaluation program performance improvement activities are conducted and reviewed by an appropriate leadership board and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
|
18-01147-47

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2020
The Chief of Staff ensures 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: 6/7/2019
The Facility Director ensures that Controlled Substances Inspection program staff have no access to or involvement in drug procurement, prescribing, or dispensing, or administration of controlled substances and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2019
The Facility Director ensures that Controlled Substances Inspectors perform reconciliation of controlled substance returns to pharmacy stock from every automated dispensing cabinet and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2019
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 compliance.
Comprehensive Healthcare Inspection Program Review of the Durham VA Medical Center, North Carolina
|
18-01146-35

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The Chief of Staff ensures that Executive Council of Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion to recommend approval of clinical privileges for LIPs and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2019
The Facility Director ensures Controlled Substances Inspectors complete monthly pharmacy prescription pad inventories and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky
|
18-01163-36

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Facility Director ensures all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Facility Director ensures the Patient Safety Manager or designee provides feedback to employees or departments who submit patient safety incidents that result in root cause analysis and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2019
The Chief of Staff ensures Focused and Ongoing Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and Fort Knox Community Based Outpatient Clinic and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The Associate Director ensures staff assigned to conduct mental health environment of care inspections use the Mental Health Environment of Care Checklist to identify and correct deficiencies in a timely manner and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The Associate Director ensures the Facility’s Emergency Operations Plan includes required elements and that the annual review of inventory and assets is conducted and documented and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2019
The Facility Director ensures that all deficiencies identified on the annual physical security survey are addressed and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2019
The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Delay in Care and Care Coordination at Cheyenne VA Medical Center, Wyoming, and Iowa City VA Health Care System, Iowa
|
18-00693-41

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Cheyenne VA Medical Center Director ensures timely surveillance for cancer patients.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Cheyenne VA Medical Center Director improves processes for care coordination and communication between Cheyenne VA Medical Center providers and non-VA providers for cancer patients.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2020
The Cheyenne VA Medical Center Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Cheyenne VA Medical Center Director confers with the Office of Chief Counsel in accordance with Veterans Health Administration Handbook 1004.08 regarding institutional disclosures and takes action as necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2019
The Cheyenne VA Medical Center Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Iowa City VA Health Care System Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/21/2019
The Iowa City VA Health Care System Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.
Delays in the Processing of Survivors' and Dependents' Educational Assistance Program Benefits Led to Duplicate Payments
|
18-01278-13

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/8/2019
The OIG recommended the Under Secretary for Benefits direct Compensation Service and Office of Field Operations to develop and implement processes and procedures that ensure monitoring of Survivors’ and Dependents’ Educational Assistance electronic mailboxes and timely establishment of compensation adjustments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2019
The OIG recommended the Under Secretary for Benefits direct Education Service to develop and implement an effective process to ensure receipt of Survivors’ and Dependents’ Educational Assistance benefit notifications by VA Regional Office staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2019
The OIG recommended the Under Secretary for Benefits ensure Compensation Service and Education Service develop electronic system functionality to identify cases with potential duplication of benefits when a dependent begins receiving Survivors’ and Dependents’ Educational Assistance payments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/19/2019
The OIG recommended the Under Secretary for Benefits ensure the National Work Queue and Compensation Service assign cases with compensation adjustments to remove the school child allowance as soon as the cases are ready for processing.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/8/2019
The OIG recommended the Under Secretary for Benefits ensure Office of Field Operations takes prompt action to adjust benefits for cases in the OIG sample in which payment duplications had not been identified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 22,500,000.00
Comprehensive Healthcare Inspection Program Review of the Iowa City VA Health Care System, Iowa
|
18-01157-31

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2019
The Chief of Staff ensures service chiefs complete all required elements, including specialty-specific criteria, for Ongoing Professional Practice Evaluations and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2019
The Facility Director ensures that controlled substances program staff complete reconciliation of controlled substances returns to pharmacy stock during controlled substance inspections and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2019
The Chief of Staff ensures that geriatric evaluation program performance improvement activities are conducted and reviewed by an appropriate leadership board or council and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the West Palm Beach VA Medical Center, Florida
|
18-01159-38

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Chief of Staff ensures that clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2019
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Director ensures implementation of root cause analysis actions and feedback of results to the reporting individuals or departments and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Chief of Staff ensures that service chiefs complete required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2020
The Chief of Staff ensures the service chiefs include service-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: 8/6/2019
The Associate Director ensures all staff are educated on how to access safety data sheet information and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2019
The Associate Director ensures the Port Saint Lucie Community Based Outpatient Clinic panic alarms are functional and regularly tested and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Pittsburgh Healthcare System, Pennsylvania
|
18-01154-27

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Chief of Staff ensures that the Medical Executive Board uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Chief of Staff ensures service chiefs complete all required elements, including minimum required specialty criteria for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Deputy Director ensures that a safe and clean environment is maintained throughout the Facility and Westmoreland County Community Based Outpatient Clinic and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The Deputy Director ensures the flooring in the mental health seclusion rooms provides cushioning.
Inadequate Governance of the VA Police Program at Medical Facilities
|
17-01007-01

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Clarify program responsibilities between the Veterans Health Administration and theOffice of Operations, Security, and Preparedness, and evaluate the need for a centralizedmanagement entity for the security and law enforcement program across all medicalfacilities.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/16/2022
Ensure police staffing models are implemented for determining facility-appropriate levelsfor officers at medical facilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2021
Make certain medical facilities use strategies to address police staffing challenges such ashaving documented recruitment plans for police officer positions that include adetermination of the need for special salary rates and incentives.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 7/11/2024

Assess the staffing levels for the Office of Security and Law Enforcement policeinspection program, and authorize and provide sufficient resources to conduct timelyinspections of police units at medical facilities to help identify program complianceissues.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/3/2021
Ensure procedures are developed for appropriately handling VA police investigations of medical facility leaders.
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