All Reports

The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events.

The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01.

The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for improvement and provided guidance on facilities’ action plans to address the deficiencies.

The OIG recommends that Veterans Integrated Service Network leaders ensure facility staff separate clean and dirty equipment and supplies to prevent cross-contamination.

The OIG recommends Veterans Integrated Service Network leaders ensure facility staff keep the environment clean and safe.

The OIG recommends that executive leaders ensure front desk personnel are competent in communicating with sensory-impaired veterans.

The OIG recommends that facility leaders consistently identify opportunities for improvement, ensure staff implement appropriate action plans, and evaluate actions for sustained improvement.

The Under Secretary for Health ensures that required suicide risk and intervention training includes suicide risk identification screening and evaluation requirements, procedures, and instruction.

The Under Secretary for Health considers establishing benchmarks for suicide risk screening and evaluation that reflect the clinical importance of suicide risk identification requirements and takes action as warranted.

The Under Secretary for Health ensures monitoring of adherence to suicide risk identification screening and evaluation setting-specific requirements.

The Under Secretary for Health ensures actions taken to address barriers to completing suicide risk screening and evaluation are effective to increase adherence to annual and setting-specific requirements in all clinical settings.

The Under Secretary for Health ensures non-mental health clinical specialty leaders are aware of and adherent to the suicide risk identification screening and evaluation requirements.

The Under Secretary for Health ensures clearly identified responsibilities for suicide risk identification screening and evaluation adherence monitoring and oversight.

The Under Secretary for Health monitors inpatient mental health unit adherence to suicide risk identification processes and identifies and addresses barriers.

The Under Secretary for Health ensures inpatient mental health unit staff complete suicide prevention safety plans as expected, and monitors compliance.

The Under Secretary for Health clarifies requirements for facility-level written guidance regarding the processes for mental health treatment coordinator identification, assignment, and care coordination, and monitors compliance.

The Under Secretary for Health ensures accurate and timely mental health treatment coordinator assignment, including patient centered management module entry and notification for the assigned staff and applicable patient.

The Under Secretary for Health evaluates the effectiveness of dedicated mental health treatment coordinators in enhancing patient engagement in outpatient mental health care following discharge from an inpatient mental health unit, and takes action as appropriate.

The Under Secretary for Health considers establishing written guidance regarding expectations for mental health unit staff to schedule patients’ post-discharge mental health care appointments.

The Under Secretary for Health determines supportive factors that contribute to patients’ attendance at outpatient mental health appointments following discharge from an inpatient mental health unit, including self-motivation enhancement and family and friend involvement, and takes action to integrate such factors into discharge planning procedures.

The Under Secretary for Health considers establishing a process for patient orientation to the behavioral health interdisciplinary team to facilitate patient awareness of, and accessibility to, team members, and takes action as appropriate.

The Ralph H. Johnson VA Health Care System Director ensures optimal mental health clinic utilization at the Hinesville VA Clinic.

The Ralph H. Johnson VA Health Care System Director ensures that mental health Hinesville VA Clinic staff are using accurate current procedural terminology codes to document services provided to patients in the electronic medical record.

The Ralph H. Johnson VA Health Care System Director confirms evaluation of administrative processes to include consult management and patient scheduling within the mental health service at the Hinesville VA Clinic and takes action as necessary to optimize patient access and experience.

The Ralph H. Johnson VA Health Care System Director completes a review of the patients identified by the Office of Inspector General to have experienced a median wait time of at least three weeks between individual therapy sessions and takes action to resolve any patient care concerns identified during the review.

The Ralph H. Johnson VA Health Care System Director considers evaluating the Choose My Therapy program at other system sites for clinic practice management deficiencies and takes action as appropriate.

The Ralph H. Johnson VA Health Care System Director ensures that all patients listed in the electronic spreadsheet have received mental health follow-up care.

The Under Secretary for Health works with the Women’s Program Office to gain an understanding of barriers to osteoporosis clinical reminder use and based on results, implement action as needed.

The OIG recommends facility leaders ensure staff secure all medications and the supplies used to administer medications in the Emergency Department.

The OIG recommends facility leaders confirm staff are knowledgeable about how the lobby kiosks function to assist veterans with sensory impairments.

The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.

The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.

The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.

The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.

The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.

The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.

The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.

The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.

The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.

The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.

The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.

Update VA’s Adjudication Procedures Manual on when personnel should request medical disability examinations and opinions.

Reduce examination and medical opinion overdevelopment by establishing a plan to continue the development of examination request tools and evaluate the effectiveness of these efforts for any future enhancements.

Correct the two errors involving prematurely denied Dependency and Indemnity Compensation claims.

Conduct a file review of the reopened Dependency and Indemnity Compensation claims granted under the PACT Act from January 1 through August 31, 2023, and take appropriate actions to ensure monetary benefits and notification letters are accurate.

Consider whether modifications could be made to the reevaluation request process consistent with the PACT Act and related regulations and, should this result in a policy change, consult with the VA Office of General Counsel.

The Under Secretary for Health ensures Veterans Health Administration leaders assess reasons for noncompliance with training requirements and takes action as warranted.

The Under Secretary for Health evaluates whether toxic exposure screening is negatively affecting primary care workload and takes action to mitigate as needed.

Implement and periodically monitor the effectiveness of a plan to provide oversight for unsent packages in the Package Manager application.

Implement a plan to address existing unsent packages in the Package Manager application.

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

Implement a more effective system life-cycle process to ensure network devices are running authorized software and operating systems that are configured to approved baselines and free of vulnerabilities.

Ensure all file systems holding veteran information are encrypted in accordance with NIST and VA policy requirements.

Maintain an accurate inventory of personnel with key access to the facility.

Enable improved audit logging capability to monitor administrator access to sensitive information hosted on the Workload Reporting and Productivity Assessing file server.

The Richmond VA Medical Center Director ensures completion of a clinical review of patient 2’s cardiothoracic surgical episode of care and takes action as appropriate.

The Under Secretary for Health ensures that consideration to reactivate the heart transplant program at the Richmond VA Medical Center includes a comprehensive analysis of transplant referral volume, leadership competency, and transplant team proficiency.

The Under Secretary for Health ensures that VA Mid-Atlantic Health Care Network and Richmond VA Medical Center leaders conduct a rigorous surveillance of quality measures if the heart transplant program is reactivated and emphasize safely meeting program target volumes to maintain clinical experience.

The Richmond VA Medical Center Director ensures the chief of surgery conducts a review of the cardiothoracic section chief’s unprofessional behaviors and develops a plan to address complaints.

The Richmond VA Medical Center Director ensures surgical leaders review cardiothoracic staff’s concerns and take action to create a culture of safety, and considers the use of resources such as the National Center for Organization Development.

The VA Mid-Atlantic Health Care Network Director develops a process for ensuring VA Mid-Atlantic Health Care Network staff provide timely and complete responses to facility leaders’ requests for clinical care reviews.

Execute the compliance plan for the Veterans Benefits Administration’s personnel suitability program.

Ensure the Veteran Benefits Administration’s personnel suitability program oversight verifies background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Establish a plan to ensure robust oversight of the National Cemetery Administration’s personnel suitability program that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Evaluate resource requirements for the personnel suitability program to ensure that all personnel suitability requirements are being met.

District leaders and the Everett and Walla Walla 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 Eugene Vet Center Director 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 Anchorage, Eugene, and Everett 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 Anchorage, Eugene, Everett, and Walla Walla 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 Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.

District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Eugene Vet Center Director determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors and ensure compliance with the requirement.

District leaders and the Eugene and Walla Walla Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

District leaders and the Kauai Vet Center Director determine reasons for noncompliance with assigning a licensed mental health professional as a clinical liaison, ensure a process is implemented, and monitor compliance.

District leaders and the Corona, Temecula, Kauai, and Western Oahu 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 Western Oahu 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 Corona, Temecula, Kauai, and Western Oahu 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 Western Oahu Vet Center Director determine reasons for noncompliance with completion of a current written outreach plan, ensure completion, and monitor compliance.

The District Director and zone leaders, in conjunction with the Corona, Temecula, and Kauai 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 Western Oahu Vet Center Director determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.

District leaders and the Corona, Temecula, and Western Oahu Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

District leaders and the Temecula and Western Oahu Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Temecula Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

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

District leaders and the Kauai and Western Oahu Vet Center Directors determine reasons for noncompliance with having an updated emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.