All Reports

The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.

The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.

Develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Ensure all relevant supply chain staff receive appropriate and recurring training and require supervisors to perform ongoing monitoring—including periodic inventory reviews and root‑cause analyses—to strengthen controls over VA supplies.

Develop and implement, in collaboration with the Veterans Integrated Service Network, local procedures that require custodial officers to notify supply chain staff when equipment is relocated, and establish protocols to validate and update equipment location and ensure equipment items are properly tagged.

Ensure expendable supplies labeled expired are, in fact, expired and appropriate documentation is completed before turning the supplies in.

Address the physical security issues discussed in this report and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouses.

Evaluate contractor performance under the contracts awarded for inventory management systems in the Augusta VA Health Care System and take appropriate action to ensure performance in accordance with the contract and to recover funds.

Ensure supply chain management staff effectively address deficiencies identified during Veterans Integrated Service Network quality control reviews.

The Associate Director keeps patient care areas clean and stores dirty and clean items separately.

Develop and establish guidance detailing how medical facility staff must document evidence to support their decisions when they make pharmaceutical purchases through the open market.

Ensure medical facility leaders conduct routine assessments of pharmaceutical purchases made through the open market so purchases are made in accordance with policy.

Develop a mechanism, in coordination with VHA’s purchase card program office and VA’s Office of General Counsel, that provides visibility into all pharmaceutical purchases, including purchases outside the prime vendor contract.

Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff periodically review unit conversion factors in the Generic Inventory Package to ensure accurate system values and quantities are recorded and then correct any discrepancies.

Require medical facility directors in Veterans Integrated Service Network 8 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.

Ensure medical facility directors in Veterans Integrated Service Network 8 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.

Ensure medical facility directors in Veterans Integrated Service Network 8 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated and establish protocols to validate and update equipment location during clinical moves or room changes and ensure equipment items are properly tagged.

Require medical facility directors in Veterans Integrated Service Network 8 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.

Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated Service Network’s quality control reviews.

Require medical facility directors in Veterans Integrated Service Network 22 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Require medical facility directors in Veterans Integrated Service Network 22 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.

Ensure medical facility directors in Veterans Integrated Service Network 22 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.

Ensure medical facility directors in Veterans Integrated Service Network 22 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated, establish protocols to validate and update the equipment location, and ensure equipment items are properly tagged.

Require medical facility directors in Veterans Integrated Service Network 22 to ensure facilities conduct annual inventory of nonexpendable equipment.

Require medical facility directors in Veterans Integrated Service Network 22 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.

Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated System Network’s quality control reviews.

The Michael E. DeBakey VA Medical Center Director uses available resources to help recruit and hire an assistant chief of Sterile Processing Services.

The Michael E. DeBakey VA Medical Center Director, in conjunction with the chief of Sterile Processing Services, reviews reusable medical device inventory management and oversight processes to ensure compliance with Veterans Health Administration requirements, identifies deficiencies, and takes action as warranted.

The Michael E. DeBakey VA Medical Center Director reviews processes to track issue briefs related to surgery cancellations resulting from reusable medical device issues from initiation to closure, identifies deficiencies, and takes action as necessary.

The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.

The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.

The Executive Medical Center Director ensures staff store clean and dirty equipment and supplies separately.

The Executive Medical Center Director ensures each service has workflows to communicate test results.

Executive leaders ensure staff properly store endoscopes.

The Medical Center Director ensures each service develops a workflow for the communication of test results.

The Medical Center Director ensures quality management staff report deficiencies identified from the External Peer Review Program to executive leaders, and staff take corrective actions as needed.

Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.

Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.

Facility leaders ensure staff label opened multidose medications with expiration dates.

Facility leaders ensure staff store clean and dirty items separately.

The Director ensures staff implement processes to prevent repeat environment of care findings.

The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.

Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.

Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.

Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.

Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.

The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.

The Executive Director ensures signs are present and accurate throughout the facility.

The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.

The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.

The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.

The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.

The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.

The Medical Center Director ensures staff properly store clean medical equipment.

Facility leaders develop written workflows for each service to ensure timely communication of test results to providers and patients.

The Director ensures staff keep the environment clean and safe.

The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.

The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.

Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.

The Executive Director ensures staff consistently label reusable medical equipment to show it is clean and ready for use.

Facility leaders install detectable warning surfaces where crosswalks transition onto a vehicle roadway.

Facility leaders ensure clinical staff who perform toxic exposure screenings complete mandatory training.

The Director ensures staff implement processes to prevent repeat environment of care findings related to dusty sprinkler heads.

Facility leaders evaluate all areas where biohazardous materials are located to ensure staff store clean and dirty items separately.

The Director ensures staff keep the environment clean and safe.

Facility leaders ensure their policy aligns with VHA Directive 1088(1) and develop workflows for all services that communicate test results to patients.

The Chief of Staff and Associate Director for Patient Care Services ensure corrective actions address unfavorable trends in communication of test result data.

The Director ensures the Chief of Staff chairs and attends the Peer Review Committee meetings as required by VHA.

The Director ensures patient safety managers identify adverse events as sentinel events when they meet criteria.

Facility leaders evaluate and improve processes to identify adverse events that warrant an institutional disclosure.

The Director implements processes to ensure staff track action plans until they are completed and report to leaders those that are outstanding.

The Director ensures leaders train staff on their roles and responsibilities when responding to a medical emergency, including the location of equipment used for medical emergencies.

The Director ensures leaders revise the emergency response policy based on recertification time frames in VHA Directive 0999(1) or sooner, if warranted.

Facility leaders ensure all applicable staff maintain basic life support certification and take appropriate action for those staff without it.

The Director ensures facility leaders manage primary care teams’ panel sizes to support patients’ access to care.

The Associate Medical Center Director ensures Environmental Management Services and nutrition staff maintain clean patient food storage areas.

The Associate Medical Center Director ensures staff monitor storage areas and remove expired supplies.

The Associate Medical Center Director ensures Environmental Management Services staff make feminine hygiene products available in public women’s and unisex restrooms.

The Chief of Staff ensures staff establish written service-level workflows for the communication of test results.

Executive leaders ensure staff store clean and dirty equipment separately, repair torn furnishings, and keep the environment clean.

Executive leaders ensure staff evaluate the cardboard backboards for pest concerns and reduce the risk of infection.

Executive leaders ensure the facility’s policy for test result communication aligns with the VHA directive.

Facility leaders ensure staff have access to sinks or hand hygiene supplies in or near soiled utility rooms that store biohazardous materials.

Facility leaders assess how staff monitor video laryngoscope supplies to ensure they are readily available, and staff remove supplies when they expire.

Facility leaders ensure staff develop service-level workflows for the communication of test results per the VHA directive.

The Associate Director ensures staff make feminine hygiene products available in public women’s and unisex restrooms.

The Medical Center Director ensures staff implement processes to secure medications from unauthorized access.

Biomedical staff indicate inspection dates on all equipment.

The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.

The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers’ recommendations.

The Executive Director ensures staff evaluate the best place to store cleaning supplies, staff store them there, and leaders monitor compliance.

The Executive Director ensures staff remove expired medical supplies and patient food items from patient care areas.

The Executive Director ensures doors in patient care areas have signs to indicate what is stored inside.