All Reports

The OIG recommends facility leaders ensure all veterans and visitors, including those who require mobility assistance, have safe and accessible pathways to clinical areas during elevator repairs.

The OIG recommends facility leaders ensure staff complete and document preventive maintenance for medical equipment.

The OIG recommends the Chief of Staff and the Associate Director, Patient Care Services ensure staff record their attendance at meetings where staff monitor the communication of test result data.

District leaders and the Evanston, La Crosse, and Milwaukee Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.

District leaders and the Evanston, Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.

District leaders and the Gary Area Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Evanston, Gary Area, and Milwaukee Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.

District leaders and the La Crosse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders determine reasons why the closing of the Milwaukee Vet Center resulted in multiple communication failures, and ensure all clients are notified of the new location, the Vet Center Call Center has accurate information, and websites include correct location and phone number information.

The Readjustment Counseling Service Chief Officer considers developing written guidance for vet center closure and temporary relocation processes including oversight responsibilities.

The OIG recommends the Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication and takes actions as needed.

The OIG recommends the Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other Veterans Integrated Service Network leaders were aware of, but did not address, facility leaders’ unprofessional behavior and communication, and takes actions as needed.

The OIG recommends the Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system, resolve medical supply deficiencies, and monitor actions for sustained improvement.

The OIG recommends facility leaders develop action plans to ensure providers communicate test results to patients timely.

The OIG recommends the Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.

The Martinsburg VA Medical Center Director reviews communication between emergency department staff to ensure timely patient care coordination, and takes action as warranted.

The Martinsburg VA Medical Center Director ensures emergency department nurses monitor, assess, and document patient care as required by Veterans Health Administration and Martinsburg VA Medical Center policy, and monitors compliance.

The Martinsburg VA Medical Center Director ensures processes are in place to ensure blood transfusions are administered according to policy, and monitors compliance.

The Martinsburg VA Medical Center Director conducts a review of actions implemented as a result of the factfinding to include administrative actions and performance improvement plans and ensures quality of care concerns have been remediated, and takes action as warranted.

The Martinsburg VA Medical Center Director evaluates the functionality of emergency room equipment, including an exam table with footrests, for conducting gynecologic examinations with dignity and comfort, and takes action as warranted.

The Martinsburg VA Medical Center Director reviews concerns related to fire department overtime practices, takes action as appropriate, and follows up to ensure compliance.

The Martinsburg VA Medical Center Director reviews the transport delay for the abdominal pain patient, and takes action as appropriate.

The Martinsburg VA Medical Center Director reviews the factfinding related to transportation concerns, ensures an adequate review is conducted, and takes action as warranted.

The Martinsburg VA Medical Center Director ensures all reported patient safety concerns related to emergency transport delays are investigated to identify root causes and contributing factors that require action to prevent future events.

The Martinsburg VA Medical Center Director ensures clear guidance is in place for clinical and administrative staff on the use of facility emergent and non-emergent transport resources.

Reduce improper and unknown payments to below 10 percent for the Pension Program.

Reduce improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program.

The OIG recommends the Associate Director of Operations ensures staff maintain, inspect, and test medical equipment.

The OIG recommends the Deputy Chief of Staff ensures staff secure all medications from unauthorized access.

The OIG recommends the Associate Director of Patient Care Services ensures staff appropriately store oxygen tanks.

The OIG recommends the Associate Director ensures staff clean all food storage areas.

The OIG recommends the Associate Director of Operations ensures staff remove expired supplies from storage areas.

The OIG recommends the Associate Director of Operations ensures staff mark equipment that needs repair and separate it from equipment available for use and remove dirty items from clean storage areas.

The OIG recommends facility leaders ensure sustained compliance with Joint Commission accreditation standards.

Improve vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.

Implement a more effective baseline configuration process to ensure network devices are running authorized software that is configured to approved baselines and free of vulnerabilities.

Improve the remediations reporting process for the Continuous Readiness in Information Security Program to verify that corrective actions are taken to fully mitigate vulnerabilities for biomedical devices at the Battle Creek facility.

Implement improved physical access controls to restrict access to the server room and communications closets.

Ensure network segmentation controls are applied to all network segments hosting special-purpose systems or medical devices.

Implement improved, consistent environmental controls for network communications closets.

The Veterans Health Administration chief operating officer establishes a written policy or procedure to reasonably ensure that potential conflicts of interest or appearance of partiality concerns involving VHA employees are identified and remediated before contractor presentations to Veterans Integrated Service Network or facility leaders. 

The Veterans Integrated Service Network 8 director confirms that VA has initiated the process to seek recoupment of the critical skill incentive paid by VA to Ms. Skala that was attributable to a service period that she did not complete due to her retirement.

The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness directs a review to determine whether any VHA employee ranked GS‑15 or above awarded a critical skill incentive has left VA before completing their required service obligation, and, if so, whether VA has established a debt and initiated recoupment in the amount of the CSI attributable to the uncompleted period, and takes further corrective actions as warranted.

The Overton Brooks VA Medical Center Director reviews and monitors compliance with Veterans Health Administration health professions trainee onboarding requirements, and takes action as indicated.

The Overton Brooks VA Medical Center Director makes certain that oversight of the intensive care unit physician credentialing and privileging process is completed prior to physicians being scheduled and providing patient care, and monitors compliance.

The Overton Brooks VA Medical Center Director ensures root cause analyses are completed according to Veterans Health Administration policy including team composition, root cause analysis process steps, and timeliness.

The Under Secretary for Health evaluates the additional root cause analysis concurrence step used within Veterans Health Administration medical centers to ensure alignment with National Center for Patient Safety guidance, and takes action as indicated.

Incorporate all business-essential processes and related interfaces, as defined by product owners, during validation sessions, user acceptance testing, or equivalent procedures to accurately present system capability.

Enhance the test plan to incorporate a more robust, risk-based testing process that incorporates user-testing requirements for functional and nonfunctional business-essential processes related to interfaces.

Develop a process to confirm with affected administrative offices whether they are aware of needed changes to test environments and that they have sufficiently executed them before interface test events.

Develop a method to evaluate whether test deficiencies necessitate changes to the deployment schedule to ensure deficiencies are properly addressed before wave go-live and implement these changes.

Take corrective actions to ensure that facilities and programs remove unauthorized sensitive information from collaborative application sites.

Direct facilities and programs to standardize SharePoint administration, inventory and consolidate their SharePoint sites, and enforce the recommended architecture to better control access and content at the facility or program level.

Implement enforcement mechanisms to ensure that facilities and programs are following standardized processes to secure SharePoint and Teams sites.

Expand roles and responsibilities of facility and program information system security officers and privacy officers to include the routine review of SharePoint and Teams site permissions and content.

Implement automated tools and policies, supported with training, to enable the timely and routine detection and correction of improper sharing and unauthorized content throughout VA.

Mandate standardized training for SharePoint administrators and owners to clarify and reinforce data security requirements.

The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.

The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.

The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.

The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.

The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.

The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.

Create a job aid for claims processors on how to determine the correct effective date for PACT Act–related claims.

Remove the outdated effective date builder from the Veterans Benefits Administration’s internal job aids page.

Continue updating the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when the Veterans Benefits Administration receives an intent to file.

Update the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when a veteran’s service connection is based on a toxic exposure risk activity.

Evaluate PACT Act refresher training by monitoring the results to assess the effectiveness of the training.

Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.

Issue a memorandum that clarifies that automatically prepopulating the clinically indicated date field of a consult is prohibited (barring officially recognized exceptions) and that it should be entered manually.

Determine whether any administrative action should be taken with respect to the conduct of the medical facility director and the chief of staff of the Omaha VA Medical Center.

Direct the medical facility director to educate and train those involved with consults on the process, including how to customize the clinically indicated date to reflect the date of care agreed to by the provider and the veteran. The training should be mandatory, its contents should comply with national policy, and its frequency should be determined by the medical facility director.

Assess the actions the medical facility has taken to review the consults that were potentially affected by the 29-day default in the clinically indicated date field and ensure veterans received the care they needed.

The OIG recommends executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.

The OIG recommends executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.

The OIG recommends executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.

The OIG recommends executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.

The OIG recommends executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.

The OIG recommends executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patient’s care.

The OIG recommends Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.

The OIG recommends executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.

Seek the opinion of the Office of General Counsel on whether the identified potential overbillings could or should be recouped.

As a part of the annual certification process of the Capital Asset Inventory, the executive director of the Office of Asset Enterprise Management should provide guidance on underground storage tank entries to ensure these assets are recorded with consistent identifying terminology in asset identification fields and with the appropriate real property predominant use code: code 40, “storage (other than buildings).”

Ensure Veterans Integrated Service Network officials fulfill their oversight responsibilities found in Veterans Health Administration Directive 1811 requiring VA medical facilities maintain a current inventory of underground storage tanks, inclusive of all associated equipment and component levels.

Ensure the assistant under secretary for health for support updates the responsibility section in Veterans Health Administration Directive 7707 to ensure that the responsibilities of VA medical facility directors include appropriate designation of staff and training for environmental regulatory requirements.

Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 to ensure facility compliance with federal, state, and local codes, laws, and regulations—including monitoring and addressing underground storage tank alarms promptly to confirm a release has not occurred.

Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 for work order (unplanned corrective maintenance) tracking from creation through completion in the approved maintenance management system—to include underground storage tank and associated component-level equipment failures or deficiencies identified in regulatory agencies’ inspections.

Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling responsibilities in Veterans Health Administration Directive 7707 to ensure regulatory compliance deficiencies are promptly reviewed, corrective actions are developed, and issues are tracked through completion to satisfactorily address environmental compliance.

Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling their oversight responsibilities found in Veterans Health Administration Directive 7707 to ensure all required federal, state, and local regulatory agencies’ inspections of underground storage tanks are recorded in the Veterans Health Administration issue brief tracking system.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety between the parking garage and bed tower entrance until completion.

The OIG recommends facility leaders improve doorway safety at the bed tower entrance by placing sensors on the two power-assisted doors, reactivating the revolving door, and monitoring doorway safety until completion.

The OIG recommends the Director ensures staff monitor the emergency exit near the laboratory to make sure the door remains unlocked and operational.

The OIG recommends the Director assesses the facility’s tactile signs (braille) and auditory cues and implements a plan to address the deficient areas.

The OIG recommends facility leaders evaluate the toxic exposure screening process and implement a plan to ensure staff complete the screenings.