All Reports

The OIG recommends facility leaders develop and implement a plan to address veterans’ unanswered phone calls.

The OIG recommends the Associate Director ensures staff identify environment of care trends and establish performance improvement plans with outcome measures to address them.

The OIG recommends the Associate Director ensures the manufacturer satisfies contractual requirements to perform preventive maintenance for beds and stretchers and documents the service.

The OIG recommends the Veterans Integrated Service Network Director works with facility and primary care leaders to address the network call center’s effect on primary care team efficiency and workload and reduce the risk of adverse patient safety events.

The OIG recommends facility leaders determine appropriate supply storage locations, and for any supplies stored outside these defined locations, implement a process to ensure staff identify and remove expired supplies.

The OIG recommends facility leaders ensure video laryngoscope supplies are readily available and not expired.

The OIG recommends the Director ensures staff keep patient care areas clean and safe.

The OIG recommends the Director ensures staff complete required preventive maintenance for biomedical equipment.

The OIG recommends facility leaders develop service-level workflows and processes to monitor communication of test results to patients.

The OIG recommends the Executive Director ensures homeless program staff have sufficient access to government vehicles to effectively function in their positions.

The OIG recommends the Executive Director ensures Housing and Urban Development–Veterans Affairs Supportive Housing program staff have access to cell phones to independently provide services to homeless veterans.

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.

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 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.

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.

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 the Director evaluates accessible parking spaces at the circle of the main entrance and ensures access aisles have visible pavement markings and remain available for use.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalks until completion.

The OIG recommends facility leaders improve doorway safety at the main entrance.

The OIG recommends the Director ensures staff have adequate hand hygiene supplies in or near soiled utility rooms that contain biohazardous materials.

The OIG recommends facility leaders ensure the facility policy for communication of test results and service-level workflows comply with VHA requirements, and staff implement processes to monitor patient notification of test results.

The OIG recommends facility leaders increase hiring efforts for the vacant social work positions in the Housing and Urban Development–Veterans Affairs Supportive Housing program, and in the interim, provide staff to support program enrollment.

Ensure supervisors conduct monitoring activities, including periodic reviews of expendable and nonexpendable inventory and root cause analyses of identified discrepancies to strengthen controls over VA supplies.

Establish routine monitoring for the accountable officer to verify the required use of barcode labels to track and identify supplies and equipment and report deficiencies for barcode replacement.

Address all unaccepted equipment and establish a requirement for custodial officers to routinely accept equipment in Maximo.

Implement a mechanism for the accountable officer to routinely monitor and ensure service‑line staff who conduct physical inventory are designated in writing by the custodial officers and receive the appropriate nonexpendable inventory training annually.

Require the accountable officer and supply chain staff to verify and update the information in the Maximo system and create procedures to ensure all nonexpendable equipment is received through the warehouse, recorded in Maximo, delivered in a timely manner to the requesting service, and accepted by the custodial officer.

Address the physical security issues identified and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouse.

Ensure all biological and nonbiological implants are recorded in the approved inventory management system and are routinely reconciled with other systems used to manage implant expiration dates.

Develop controls to ensure implant program staff identify and create local agreements for existing consignment implants and establish agreements for future consignment implants in accordance with national guidance.

Officially designate a facility implant coordinator and establish a monitoring mechanism to ensure compliance with implant coordinator roles and responsibilities.

Update the local implant management policy to clarify roles and responsibilities and to train staff in these roles about their implant management responsibilities.

The Carl Vinson VA Medical Center Director ensures applicable staff, such as Sterile Processing Services staff and end users of reusable medical devices, comply with procedures regarding the identification of and disposition of nonconforming surgical instruments.

The Carl Vinson VA Medical Center Director confirms operating room staff completes training regarding the recognition of and procedures for nonconforming surgical instruments.

The VA Southeast Network Director establishes a comprehensive strategy to review patients who may have been affected by the approximately 800 nonconforming surgical instruments to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of disclosures.

The VA Southeast Network Director evaluates whether administrative action is warranted for employees regarding Sterile Processing Services deficiencies at the Carl Vinson VA Medical Center, and takes action as appropriate.

The VA Southeast Network Director provides consultation and oversight to the Carl Vinson VA Medical Center’s Sterile Processing Services to ensure implementation of facility-level action plans and sustainability of identified outcomes.

The OIG recommends that facility leaders review and correct any outdated navigational signage.

The OIG recommends facility leaders define and assign roles and responsibilities to toxic exposure screening navigators and ensure program oversight.

The OIG recommends the Director ensures staff keep patient care areas safe and clean.

The OIG recommends the Director ensures biohazard storage areas display proper signage, have appropriate hand-washing supplies and equipment available, and do not contain housekeeping supplies.

The OIG recommends the Associate Director ensures staff identify one or more facility environment of care trends and establish a performance improvement plan, including outcome measures, to address them.

The OIG recommends that facility leaders continue to develop and implement administrative processes to ensure ordering providers promptly communicate and document test results.

The OIG recommends that facility leaders ensure staff maintain and reference current VHA requirements and update facility-level policies and standard operating procedures to comply with them.

The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.

The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.

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.

Track facilities’ supply chain personnel vacancies as part of the quality control reviews and take appropriate action.

Develop guidelines that define when facility supply chain management problems require additional interventions and then routinely identify them for network director action.

Ensure facility and network directors work with the Procurement and Logistics Office on a plan to identify resources and milestones to resolve identified supply chain management problems for identified facilities.

Direct the program office to develop a process to provide resources when needed to help networks and facilities resolve persistent supply chain management deficiencies, including those identified in this report.

Continue Procurement and Logistics Office efforts to automate tracking that will accurately capture and monitor all quality control review results, corrective action plans, and implementation of those plans.

Update the Procurement and Logistics Office audits of the quality control program to apply risk‑based sampling, evaluate action plan sufficiency and implementation, and use the results to continuously improve quality control review guidance and requirements.

Ensure facility staff place all orders for eligible items through the Medical/Surgical Prime Vendor program, including those that are identified as on back order.

Implement tracking mechanisms for back orders to assist the facilities in not obtaining excess supplies.

Ensure that logistics staff receive training and use the Prime Vendor Conversion and Recommendation Tool to identify commonly purchased open market items and convert those items to Medical/Surgical Prime Vendor purchases.

Identify and implement an efficient way to transfer product list updates to the inventory ordering system.

In collaboration with the Strategic Acquisition Center, identify a VA-owned system for staff to check product information, such as availability and pricing, and ensure applicable facility staff are aware of this location.

Implement a standardized, routine review of open market purchases.

Ensure that reporting tools are effective and consistently applied, and that reported issues are resolved.

Ensure that logistics staff receive relevant Medical/Surgical Prime Vendor program guidance and training.

Ensure the product list includes items that facilities need and regularly purchase so the Veterans Health Administration can expand the savings and benefits the Medical/Surgical Prime Vendor program offers.

The VA Desert Pacific Healthcare Network Director strengthens Sterile Processing Service oversight to ensure timely communication of audit findings with action plan expectations to facility leaders.

The VA Desert Pacific Healthcare Network Director ensures entry of audit results into the Sterile Processing Accountability Tool within the required time frame.

The VA Desert Pacific Healthcare Network Director ensures audit results are shared with the Sterile Processing Advisory Board per Veterans Health Administration requirements.

The VA New Mexico Health Care System Director ensures Sterile Processing Service has a process to communicate all instances when high-level disinfection documentation cannot be located to the associated clinical services when the reusable medical devices was used in patient care.

The VA New Mexico Health Care System Director ensures Sterile Processing Service has a formal process in place to sustain daily quality assurance reviews and monitors compliance.

The VA New Mexico Health Care System Director ensures Sterile Processing Service leaders demonstrate clear communication of Sterile Processing Service staff roles and responsibilities in accordance with Veterans Health Administration High Reliability Organization principles and values.

The VA New Mexico Health Care System Director ensures the facility’s Sterile Processing Service identifies and resolves high-level disinfection documentation errors as they occur, prior to use of associated reusable medical devices on patients.

Ensure the DALC Recreation Group’s operations fully comply with VA Handbook 5025, Part VIII, or dissolve the group if there is insufficient employee interest in its continuation.

Update VA Handbook 7002, Logistics Management Procedures Part 3, section 7, to clarify under which circumstances, if any, VA employees are permitted to request, accept, and record any incentive items provided by vendors in connection with government purchases.

Reinforce ethics and policy requirements on the acceptance and disposition of free or donated property with all Denver Logistics Center managers and staff, including distributing to staff the Office of General Counsel’s guidance dated June 30, 2023.

Reeducate DLC managers, approving officials, and purchasing agents about VA government purchase card policy requirements that government contracted sources be fully considered and given priority when making purchases.

In consultation with the Office of General Counsel, as authorized by 31 U.S.C. § 3711, determine the full magnitude of the loss from the DALC Recreation Group’s improper sale of VA property and take appropriate action to recover the losses, including any proceeds of the auctions currently within the custody or control of the DALC Recreation Group.

Consider whether any administrative action should be taken with respect to the conduct or performance of the director of the Denver Logistics Center or any other individual involved in the improper acquisition and disposition of the incentive items, and report to the OIG any actions taken involving these individuals.

The Carl Vinson VA Medical Center Director ensures that the Sterile Processing Services chief conducts comprehensive staff competency assessments for the reprocessing of reusable medical equipment, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that the CensiTrac Instrument Tracking System is fully implemented, and that training is provided to the CensiTrac coordinator and Sterile Processing Services staff, and monitors for compliance.

The Carl Vinson VA Medical Center Director evaluates and ensures that Sterile Processing Services maintains a safe and clean environment in all areas where decontamination, sterilization, or clean and sterile storage of reusable medical equipment are performed, and monitors for compliance.

The Carl Vinson VA Medical Center Director develops an action plan for remediation of the location and use of the training room adjacent to Sterile Processing Services’ clean and sterile storage area, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that clinic areas, including radiology, have or share a designated soiled utility room as required by Veterans Health Administration policy, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that Sterile Processing Service standard operating procedures for reusable medical equipment are developed, updated consistent with manufacturer’s instructions for use, disseminated, and available at the point of use, and monitors for compliance.

The Veterans Integrated Service Network Director reviews the facility’s Sterile Processing Service water management program and takes action as necessary to ensure compliance with Veterans Health Administration guidance, and monitors for compliance.

The Carl Vinson VA Medical Center Director ensures that the facility Water Working Group submits critical water system test results to the Veterans Integrated Service Network Sterile Processing Services Management Board, as required, and monitors for compliance.

The Veterans Integrated Service Network Director ensures all critical water system test results are reviewed by the Veterans Integrated Service Network Sterile Processing Services Management Board, corrective action is taken when appropriate, and all corrective actions are reported to the National Program Office for Sterile Processing, and monitors for compliance.

Implement oversight, monitoring, and quality assurance mechanisms that routinely ensure all goods received by the Denver Logistics Center are accurately and promptly recorded in the inventory management system at the time of receipt.

Properly record all apnea stock in the inventory management system.

Ensure Denver Logistics Center management routinely assess the appropriateness of manual adjustments to the inventory system and document the findings and causes, review trends in error codes, and develop action plans to minimize inaccuracies in future physical counts.

Strengthen controls over inventory adjustments to ensure the accountable officer or designee reviews and approves supply variances above an established threshold.

Establish and implement policy that clearly defines roles and responsibilities for Denver Logistics Center logistics and warehouse employees, separates duties to avoid conflicts of interest, and enhances the quality assurance function.

Establish and implement formal policies and procedures specific for inventory management operations at the Denver Logistics Center, to include cycle counts, regular inventory audits, adjustments and forecasting demand, safety levels, reordering, and tools to allow for automated scanning.

Develop and deliver formal training to logistics and warehouse staff on inventory management policies, procedures, and tools.

Implement routine reporting of all Denver Logistics Center inventory adjustments to the National Acquisition Center and the Office of Acquisition, Logistics, and Construction.

Ensure the Denver Logistics Center staff complete reports of survey for adjustments to inventory in accordance with VA logistics management policy, and communicate such information to the National Acquisition Center.

Address the physical security issues identified and develop, implement, and provide initial and recurring training and guidance to Denver Logistics Center’s logistics, distribution, and contract staff on proper physical security controls and procedures, including the proper disposal of personally identifiable information.

Conduct an independent, comprehensive, and multiyear financial audit that includes wall-to-wall inventory assessments of the Denver Logistics Center.

Transfer the stewardship and responsibility for Denver Logistics Center systems to the Office of Information and Technology.

In collaboration with the Office of Information and Technology, establish information system controls for user access, segregation of duties designations, permission access, and privilege access for the inventory management systems and data.

Establish and perform routine reviews of the access levels for users with direct access to the inventory management systems and ensure that access is limited to those who have a defined business purpose.

In collaboration with the Office of Information and Technology, ensure the Denver Logistics Center meets physical access, security, and contingency planning requirements for its information management systems.

Establish a connection for Denver Logistics Center inventory data to VA’s Corporate Data Warehouse.

In collaboration with the Office of Information and Technology, ensure the information technology system application does not bypass internal control restrictions, has a complete audit trail, and does not introduce errors in the information system.

Ensure the Denver Logistics Center develops and maintains comprehensive documentation of the information system to support operations and train information resource management staff.

Ensure security documentation accurately supports the proper controls are implemented, tested, and representative of the system security.