All Reports

Comprehensive Healthcare Inspection Program Review of the Roseburg VA Health Care System, Oregon
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18-00620-277

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly defined timeframes and monitors the clinical managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Chief of Staff ensures Focused Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2019
The Chief of Staff ensures that the Executive Council of Medical Staff uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2019
The Chief of Staff ensures that clinical managers consistently collect and maintain Ongoing Professional Practice Evaluation data and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2018
The Associate Director ensures Nutrition & Food Service staff store cleaning solutions separately from food items and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2018
The Interim Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and that controlled substances coordinators refrain from conducting routine inspections and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2019
The Interim Director ensures that reconciliation of controlled substance returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Review of Pain Management Services in Veterans Health Administration Facilities
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16-00538-282

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Under Secretary for Health ensures that VA facilities have formal processes in place for providers to access state prescription drug monitoring programs to reconcile medications dispensed by private providers and those dispensed by VA, and that this process is in compliance with the providers’ state licensing requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Under Secretary for Health evaluates the use of facility-specific panel readjustments or other means of increasing resources for primary care providers who manage chronic pain conditions for a significant proportion of his/her panel and takes action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2021
The Under Secretary for Health evaluates and determines the adequacy of the number of pain specialists at each facility through formalized assessments and takes action as appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2021
The Under Secretary for Health ensures that VA facilities without pain specialists have formalized designated resources of pain care provided by providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Under Secretary for Health evaluates the use of pain assessment tools across the Veterans Health Administration to ensure that those tools used by facilities provide information that improves oversight to patients who are treated for chronic pain conditions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2019
The Under Secretary for Health develops a formal evaluation of the provision of pain management services within VA to complement the Opioid Safety Initiative.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
The Under Secretary for Health ensures that VA’s practice of routine and random urine drug tests both prior to initiating and during take-home opioid therapy to confirm the use of opioids is in alignment with guidelines.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/13/2019
The Under Secretary for Health ensures that opioid patients with active (not in remission) substance use disorder undergo urine drug testing and receive treatment for the substance use disorder.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
The Under Secretary for Health evaluates and determines that VA’s practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with guidelines.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
The Under Secretary for Health ensures that medication reconciliation is performed to prevent adverse drug interactions.
Delays and Deficiencies in Obtaining and Documenting Mammography Services at the Atlanta VA Health Care System, Decatur, Georgia
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17-02679-283

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2019
The Atlanta VA Health Care System Director ensures that a review is conducted of patients with mammography orders in an active, pending, or scheduled status as of October 28, 2015, to ensure that clinical care was provided and results are documented in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2019
The Atlanta VA Health Care System Director makes certain that Medical Center Memorandum 11-04, Health Care for Women Veterans, May 17, 2016, is updated to reflect current Facility processes, including but not limited to mammography coordinator responsibilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2019
The Atlanta VA Health Care System Director ensures compliance with Veterans Health Administration Directive 1232(1), Consult Processes and Procedures (amended September 23, 2016), including the completion of mammograms by the order date or the date the physician requested the study be completed and that a process is established for review when consults exceed established timeliness thresholds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2019
The Atlanta VA Health Care System Director improves mammography processes to schedule appointments and receive, account for, scan, upload, and provide external diagnostic imaging results to the appropriate clinical areas and Veterans Health Administration providers and that the process is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2019
The Atlanta VA Health Care System Director confirms that clinical appropriateness reviews of mammography consults are performed to ensure that the correct imaging study is ordered for the patient’s clinical presentation and that performance of reviews is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Atlanta VA Health Care System Director verifies that providers who are trained in provision of women veterans health care are designated as Women’s Health Primary Care Providers, have the required number of women assigned to their panel, and provide gender specific care in accordance with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Atlanta VA Health Care System Director provides executive level oversight of the Women Veterans Program to ensure that service level functions are coordinated, processes are streamlined, and identified actions are tracked to resolution.
Inpatient Security, Safety, and Patient Care Concerns at the Chillicothe VA Medical Center, Ohio
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17-04569-262

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019

The Chillicothe VA Medical Center Director ensures that the windows of patient care areas remain secure in accordance with Veterans Health Administration Center for Engineering and Occupational Safety and Health guidelines.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2019

The Chillicothe VA Medical Center Director makes certain that the Chillicothe VA Medical Center’s policy for Special Observation is followed and monitors for compliance.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2019

The Chillicothe VA Medical Center Director verifies that training and staff competencies are completed for Prevention and Management of Disruptive Behavior and Special Observation as required.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019

The Chillicothe VA Medical Center Director confers with the Office of Chief Counsel regarding the notification of the patient’s death and discussion of institutional disclosure with the next-of-kin and takes action as appropriate.

Illicit Fentanyl Use and Urine Drug Screening Practices in a Domiciliary Residential Rehabilitation Treatment Program at the Bath VA Medical Center, New York
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17-01823-287

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2019
The Veterans Health Administration Under Secretary for Health ensures that drug screening guidelines for VA facilities are reviewed to determine if fentanyl should be included in routine urine drug screening, and takes appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Veterans Health Administration Office of Mental Health Services, Substance Use Disorders, Director considers developing and implementing a monitoring program to identify regional trends of drug abuse for facilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Veterans Integrated Service Network 2 Director evaluates laboratory processes for fentanyl test results and takes appropriate action to ensure timely turnaround times and notification of results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2018
The Bath VA Medical Center Director ensures accurate tracking and monitoring of positive urine drug screening data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Bath VA Medical Center Director ensures that all Domiciliary Residential Rehabilitation Treatment Program clinical staff are trained on the interpretation of urine drug screening laboratory results.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2019
The Bath VA Medical Center Director consults with appropriate personnel including ethics, legal counsel, privacy office, suicide prevention, and relevant Veterans Health Administration Program Office Directors to evaluate the risk identification/color-coded sticker system and ensure the practice is consistent with privacy standards and best practices.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2018
The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided personal protective equipment for use while conducting searches of resident belongings and rooms.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2019
The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided training on conducting safe and effective searches of resident rooms and belongings.
Leasing Procedures Used to Acquire VA’s Wilmington Health Care Center
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16-04658-250

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/16/2019
The OIG recommended the Executive Director for Construction and Facilities Management establish and disseminate a formal policy for transferring contract files when transferring responsibilities to a different contracting officer.
Comprehensive Healthcare Inspection Program Review of the Battle Creek VA Medical Center, Michigan
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18-01139-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Director ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The Chief of Staff ensures that clinical managers initiate and complete Focused Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2019
The Chief of Staff ensures that clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi
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18-00608-247

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Facility Director ensures that an interdisciplinary facility group reviews utilization management data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to Facility leaders at the completion of each fiscal year and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2019
The Chief of Staff ensures that Executive Committee of the Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion in order to recommend approval of clinical privileges for licensed independent practitioners and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired licensed independent practitioners and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2020
The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2020
The Associate Director ensures required team member participate in environment of care rounds and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2019
The Associate Director ensures sterilized surgical instruments in the podiatry clinic are appropriately labeled with expiration dates or statements and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that the Alternate Controlled Substance Coordinator’s position description or functional statement includes an addendum for the Controlled Substance Coordinator’s duties and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that monthly controlled substance inspections are completed in all required areas and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2019
The Facility Director ensures that all controlled substance inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that required pharmacy inspections are completed monthly and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2020
The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive Posttraumatic Stress Disorder screens and monitors compliance.
VA Policy for Administering Traumatic Brain Injury Examinations
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16-04558-249

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/10/2018
The Under Secretary for Benefits coordinate with the Under Secretary for Health to determine whether veterans who had received initial TBI medical examinations by VHA-contracted examiners and not by one of the four designated specialists, were unintentionally excluded from equitable relief. If additional veterans are identified, the OIG requests that those cases be referred to the VA Secretary for consideration of equitable relief.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/13/2019
The Under Secretary for Benefits confirm whether the names of veterans who were not on the initial list of veterans entitled to equitable relief and later identified by VBA staff and referred for potential equitable relief were submitted to the VA Secretary for consideration. The OIG requests an update of the current status and disposition of those cases.
Review of Accuracy of Reported Pending Disability Claims Backlog Statistics
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16-02103-265

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2019
The OIG recommended the Under Secretary for Benefits consider revising which claims are included in VBA’s reported disability claims backlog and provide a clear definition to all stakeholders.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/28/2019
The OIG recommended the Under Secretary for Benefits implement a plan to provide consistent oversight and training of Claims Assistants through national performance and training plans.
Bulk Payments Made under Patient-Centered Community Care/Veterans Choice Program Contracts
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17-02713-231

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
The Executive in Charge, Office of the Under Secretary for Health, continue to support processes to prevent duplicate payments made to third-party administrators through the bulk payment process and ensure that proper controls are in place to prevent duplicate payments to third-party administrators through all other current payment methodologies and under future Community Care contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The Executive in Charge, Office of Under Secretary for Health, ensure that Office of Community Care staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant government authorities to review and determine an appropriate process for reimbursement of overpayments by the third-party administrators.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 101,400,000.00
Comprehensive Healthcare Inspection Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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18-01013-263

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
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: 4/5/2019
The Associate Director ensures the VA Police regularly test panic alarms at the Hot Springs community based outpatient clinic and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing at the locked mental health unit and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2019
The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures that reconciliation of controlled substances dispensing from the pharmacy to every automated dispensing cabinet and returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures that controlled substances inspectors verify written controlled substance orders during monthly area inspections and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures controlled substances inspectors complete emergency drug cache inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2019
The Chief of Staff ensures providers complete suicide risk assessments within the required timeframe for patients with positive post-traumatic stress disorder screens and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures that the Joint Leadership Council maintain oversight of all geriatric evaluation program performance improvement activities and monitors compliance.
Intraoperative Radiofrequency Ablation and Other Surgical Service Concerns, Samuel S. Stratton VA Medical Center, Albany, New York
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17-01770-188

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Veterans Integrated Service Network Director ensures that the Facility’s credentialing and privileging program is reviewed for integration of key functions of quality oversight, including the use of quality data for Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation processes and surgical Peer Review program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures that the Facility Peer Review program meets all Veterans Health Administration requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2019
The Facility Director ensures that Surgery Service’s professional practice evaluations include performance data to support provider privileges and contain accurate data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2019
The Facility Director ensures that a process is developed and implemented to document, report, and track patient cases discussed in the Liver Tumor Board and that meeting minutes are completed and forwarded to oversight groups.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2019
The Facility Director ensures that a process is implemented to track, monitor, and report intraoperative radiofrequency ablation outcomes to Facility and Quality Management leaders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Facility Director ensures that the Office of General Counsel is consulted on the three patients with missed or partially missed tumors after intraoperative radiofrequency ablation to determine if institutional disclosure might be appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures that the five additional intraoperative radiofrequency ablation patients the Office of Inspector General referred to the Facility, and any other patients who had intraoperative radiofrequency ablation done by Surgeon A, are reviewed by clinicians with qualifications to assess the outcome of these procedures and actions taken as appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures an external review of intraoperative radiofrequency ablation processes is obtained to identify possible causes of missed tumors and methods to improve practice and outcomes.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures that Human Resources and the Office of General Counsel are consulted to determine the appropriate actions, if any, including consideration for ethics review, for staff who were not forthcoming with patients on outcomes of intraoperative radiofrequency ablation.
Accuracy of Effective Dates for Reduced Evaluations Needs Improvement
|
17-05244-226

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2018
The Under Secretary for Veterans Benefits Administration implement a plan to ensure staff timely process cases with reduced evaluations, after the decision, to prevent rework and improper payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/12/2020
The Under Secretary for Veterans Benefits Administration establish a plan to modify the Veterans Benefits Management System to apply correct effective dates for cases with reduced evaluations for conditions that were no longer service-connected and alert staff when the assigned effective dates are improper.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2018
The Under Secretary for Veterans Benefits Administration remind VA Regional Office staff of the system defect that causes effective dates to be one month later than required for conditions that are no longer being classified as service-connected, until the Veterans Benefits Administration could implement a system change.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/28/2019
The Under Secretary for Veterans Benefits Administration implement a plan to provide refresher training on the proper processing of reduced evaluations to staff who process rating reductions and monitor the effectiveness of that training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/7/2019
The Under Secretary for Veterans Benefits Administration provide updated guidance to include provisions for when amended proposal letters are necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/8/2021
The Under Secretary for Veterans Benefits Administration implement a plan to conduct periodic reviews for veterans who had evaluations reduced after the first of the month following the final notification letter and before the first of the month following 60 days after the final notification letter, take corrective actions as needed, and provide certification of completion to the Office of Inspector General.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,900,000.00
Comprehensive Healthcare Inspection Program Review of the Bay Pines VA Healthcare System, Florida
|
17-01857-264

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The Associate Director ensures that floors in patient care areas are clean and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The Facility Director ensures that the Alternate Controlled Substances Coordinator’s position description or functional statement includes the Control Substance Coordinator’s duties and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2019
The Chief of Staff ensures that the Geriatric Evaluation Social Worker performs the required comprehensive psychosocial assessment and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The Associate Director for Patient Care Services ensures that all staff involved in inserting and managing central lines receive the required central line-associated bloodstream infection prevention training and monitors compliance.
Use of Not Otherwise Classified Codes for Prosthetic Limb Components
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16-01913-223

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should review the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (August 2011, March 2013, and August 2013), coordinate with appropriate officials to determine which Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes are appropriate to classify these items for reimbursement, and issue revised guidance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2019
The Executive in Charge, Veterans Health Administration, should coordinate with appropriate officials to establish a formal oversight and reporting structure that defines the roles and the responsibilities of the Prosthetic and Sensory Aids Service Orthotic and Prosthetic L Code Committee, as well as who has the authority to approve recommendations for the use of the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes to classify specific prosthetic components for reimbursement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should develop and implement effective processes and procedures to monitor the use of Not Otherwise Classified codes and communicate these procedures to the Veterans Integrated Service Networks to ensure compliance with Veterans Health Administration Directive 1045, Healthcare Common Procedure Coding System (HCPCS) List for Prosthetic Limb and/or Custom Orthotic Device Prescription (December 30, 2013) and the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II Coding Procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2019
The Executive in Charge, Veterans Health Administration, should coordinate with the appropriate officials to develop and implement processes and procedures to ensure any pricing guidance with regard to the pricing of prosthetic items classified using a Not Otherwise Classified code is developed and concurred with by VA Office of General Counsel and Veterans Health Administration’s Procurement and Logistics Office prior to issuance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should issue corrected guidance to replace the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (March 2013 and August 2013) and the prosthetic limb contract template issued in August 2014, by coordinating with appropriate officials to develop and implement pricing guidance to ensure VA pays a fair and reasonable price for items classified using a Not Otherwise Classified code.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 21,300,000.00
Comprehensive Healthcare Inspection Program Review of the VA St. Louis Health Care System, Missouri
|
18-00612-260

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: 4/1/2019
The Chief of Staff ensures that clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2018
The Facility Director ensures that the duties of the Alternate Controlled Substances Coordinator are included in the employee position description or functional statement and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Facility Director ensures that Controlled Substances Inspectors are appointed in writing prior to performing inspector duties and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2019
The Facility Director ensures that controlled substances inspections are completed monthly in all clinical areas and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Chief of Staff ensures that ordering providers are notified of all mammography results and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
|
18-00600-259

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: 8/22/2018
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Associate Director ensures that Facility managers maintain clean floors in patient care areas and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Associate Director ensures that Facility managers ensure that damaged equipment in patient care areas is repaired or removed from service and that Facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Chief of Staff ensures that mammogram reports are scanned into Veterans Health Information Systems and Technology Architecture Imaging and are viewable by all members of the healthcare team and that Facility managers monitor compliance.
Comprehensive Healthcare Inspection Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri
|
18-01011-253

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures the emergency power supply system inspections are performed weekly and monitors compliance.
Processing Inaccuracies Involving Veterans' Intent to File Submissions for Benefits
|
17-04919-210

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/18/2019
The OIG recommended the Under Secretary for Benefits take steps to prioritize the modernization of functionality within the Veterans Benefits Management System to assist rating personnel with assigning correct effective dates related to intent to file.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2019
The OIG recommended the Under Secretary for Benefits implement a plan to conduct a special review of claims with intent to file submissions from March 24, 2015, through September 30, 2017, during which payment changes occurred, to determine whether rating personnel assigned correct effective dates when awarding compensation benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 72,500,000.00
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