All Reports

We recommended that the System Director ensure that the care of Patient A is evaluated, including a review of computerized tomography scan orders and imaging study results, and take action if appropriate.

We recommended that the System Director consider revising the Do Not Resuscitate Policy to include re-addressing Do Not Resuscitate orders status with patients prior to any procedures in the hospital.

We recommended that the System Director ensure timely compliance with all elements of the Drug-Free Workplace Program.

We recommended that the Facility Director initiate a clinical review of this case and take appropriate actions to educate providers, if indicated.

We recommend that the Director, VBA Continental District, confer with the Offices of General Counsel (OGC), Human Resources (OHR), and Accountability Review to determine the appropriate administrative action to take, if any, against Ms. Murphy.

We recommend that the Director, VBA Continental District, review whether the privilege of credit hours and telework should be revoked and ensure that Ms. Murphy receives refresher training on VA’s policy for time and attendance, credit hours, and telework.

We recommend that the Director, VBA Continental District, confer with OGC and OHR concerning the 14 days in which Ms. Murphy was unable to fully account for her activities, determine whether she was absent without approved leave, and initiate action to recover pay she received when she was not present for duty.

We recommend that the Director, VBA Continental District, ensure that any VARO local policy for credit hours complies with VA policy and that employees use VA Form 5631 or the ETA system as the official means to record, certify, and report their time and attendance, to include any compensatory or credit hours earned or used.

We recommended the Under Secretary for Health implement an oversight process to ensure Integrated Oversight Process reviews arecompleted in accordance with established policies.

We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, develop a mechanism to ensure effective coordination between acquisition personnel when transferring contracting responsibilities.

We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, implement a process to ensure all acquisition personnel record contracting actions in the Electronic Contract Management System.

We recommended that the Veterans Integrated Service Network Acting Director ensure that Facility Directors reassign or redistribute primary care patients to other primary care teams as required by the Veterans Health Administration and monitor compliance.

We recommended that the Acting Veterans Integrated Service Network Director ensure that the Facility Director reviews Primary Care Management Module data and reports and takes steps to follow Veterans Health Administration guidance for primary care provider panel sizes across the system.