All Reports

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

The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.

The OIG recommends facility leaders implement actions to correct the electrical issue in the Emergency Department Main 2 area and mitigate the risk until it is resolved.

The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.

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The OIG recommends that facility leaders review and correct any outdated navigational signage.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

Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.

Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.

Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.

Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantee’s premises and any adverse health or safety inspection results or similar findings made concerning the grantee’s premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.

Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSD’s clinical treatment housing model.

The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.

The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.

The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.

The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes solo and two-deep practitioners’ professional practice evaluations in a timely manner.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network chief medical officers and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes Ongoing Professional Practice Evaluations of chiefs of staff in each facility in a timely manner.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, reviews state licensing board reporting processes at the network level to ensure compliance with Veterans Health Administration policy.

The Under Secretary for Health, in conjunction with the Veterans Integrated Service Network 8 Director, ensures the Chief Medical Officer oversees each facility’s annual self-assessment and confirms responses reflect accurate data.

Make sure the Office of Integrated Veteran Care develops contract language and/or maximum allowable rates to limit reimbursements that do not have a Medicare or VA fee schedule rate for Community Care Network claims.

Ensure the Office of Integrated Veteran Care improves oversight of healthcare claim payments to prevent, identify, and recover overpayments in a more timely manner.

Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction, collaborate to extend the contracting officer’s representatives’ designated responsibilities to include monitoring of healthcare invoices.

Make sure the Office of Integrated Veteran Care considers including dental contract reimbursement language in the current and/or future contracts that is consistent with other contract healthcare reimbursement methodology to limit dental contract reimbursements, not to exceed the amount the third-party administrators pay the providers.

Make certain the Office of Procurement, Acquisition, and Logistics develops sufficient oversight and internal controls over the contract modification process to prevent program overpayments.

Require the Office of Veteran Integrated Care and the Office of Acquisition, Logistics, and Construction to collaborate to explore potential recovery of dental payments to Optum.

Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction collaborate to establish oversight and internal controls for dental services provided through Community Care Network to prevent excessive reimbursements.

The VA Northern Indiana Healthcare System Director evaluates the system clinic cancellation policy and Chief of Staff notification of urgent clinic cancellations and takes action as appropriate.

The VA Northern Indiana Healthcare System Director reviews short-notice clinical cancellations for social work mental health clinics, including the provider’s clinic, to evaluate patient impact and take actions as appropriate.

Establish a plan to use VA’s cost accounting system information to identify additional ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy.

Ensure the facility has a process to identify cost outliers, such as using the Intermediate Product Cost Outlier report to identify cost outliers that may occur at the healthcare system on a regular basis.

Ensure healthcare system service lines review and update the national labor mapping tool to the Veterans Integrated Service Network managerial cost accounting team as required by VA financial policy to ensure workload is being captured correctly.

Ensure that healthcare system staff and responsible finance office staff review all open obligations to ensure balances are valid and should remain open or are closed in a timely manner as required by VA Financial Policy, “Obligations,” as updated in March 2024.

Ensure that the healthcare system uses appropriated funds in the manner intended by Congress, as required by the VA Financial Policy, “Obligations,” as updated in March 2024.

Consult with the Office of General Counsel and the Office of Acquisitions, Logistics, and Construction to determine whether a bona fide needs or other appropriations law violation occurred and, if any violations did occur, take appropriate remedial and preventive actions to address them.

Ensure cardholders comply with prior approval, segregation of duties, and record retention requirements as required by VA Financial Policy, volume 16, chapter 1B, “Government Purchase Card for Micro-Purchases.”

Ensure cardholders and approving officials are aware of the requirement to review purchases and determine when it is in the best interest of the government to use strategic sourcing.

Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package and ensure processes are in place to monitor performance metrics in accordance with Veterans Health Administration policy.

Develop and maintain an effective standardized training program for new and current inventory staff and monitor the staff’s knowledge and skill level.

In coordination with the Strategic Acquisition Center, ensure that the Medical Surgical Prime Vendor facility-level contracting officer’s representatives and ordering officers are appointed and delegated properly and perform all required duties according to the scope and limitation of the designee’s authority.

In coordination with the Strategic Acquisition Center, submit ratifications for any Medical Surgical Prime Vendor unauthorized commitments in accordance with the Federal Acquisition Regulation.

The Executive Director mitigates the impact of construction on patient care in the Emergency Department.

The Chief of Staff ensures the toxic exposure screening navigators verify data to track veterans waiting for secondary screenings and address any backlog.

Establish Veterans Benefits Management System–Fiduciary records for the 311 identified beneficiaries within the Veterans Benefits Management System.

Start or resume required oversight activities, such as field examinations, to assess the well-being and protection of VA funds for the 311 identified beneficiaries.

Implement controls to identify when beneficiaries deemed incompetent do not have electronic fiduciary records and to ensure records are established in the required system(s).

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that service chiefs responsible for required invasive procedure infrastructure services ensure the completion of the annual review of infrastructure and that existing infrastructure is accurately reported.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures that requirements and processes for invasive procedure complexity infrastructure waiver requests are clearly communicated to facility leaders.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director reviews the process for tracking invasive procedure complexity infrastructure waiver requests, and takes actions as needed to avoid delays in review and submission.

The Under Secretary for Health ensures that guidance provided to Veterans Integrated Service Network and facility leaders regarding the invasive procedure complexity infrastructure waiver request process is clear and consistent with Veterans Health Administration Directive 1220(1).

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director confirms that acute and emergent patient transfer times related to waived infrastructure requirements are tracked and monitored, identifies trends or adverse patient outcomes, and takes actions as warranted.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director directs the chief of surgery, or designee, to attend blood utilization review committee meetings per facility requirements, and ensures compliance.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews the care provided to patient B to confirm compliance with Veterans Health Administration Directive 1004.08, determines if an institutional disclosure is warranted, and takes action as required.

The Under Secretary for Health reviews Veterans Health Administration Directive 1400.01 to confirm that the supervision of PGY-1 surgery residents and guidance provided to Veterans Health Administration facilities aligns with Veterans Health Administration policy and Accreditation Council for Graduate Medical Education program requirements.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that operative documentation is completed per facility policy, reviews the methodology for monitoring operative documentation compliance, and takes action as necessary.

The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews and monitors staff and health professional trainee compliance with the rules of behavior as it applies to authorized access to all VA computer programs including clinical applications.

The Under Secretary for Health evaluates the process for granting authorized access to VA computer systems for health profession trainees and takes steps to ensure access is provided by the start of trainee rotations at VA facilities.

The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures the corrective actions developed by facility leaders to address surgical intensive care unit patient safety concerns are completed and evaluated for effectiveness.

Use up-to-date contact center data and the recommended Veterans Health Administration call center staffing model to ensure the clinical contact center is operating within indicated target staffing goals.

Evaluate call center staffing and call data for clinical contact center staff based at the Atlanta facility to identify possible operational inefficiencies related to scheduling, handle time, and availability for calls, and address inefficiencies as needed.

Periodically evaluate the performance of health administration services staff who answer specialty care clinic calls at the Atlanta facility to ensure they meet Veterans Health Administration call center performance standards.

Evaluate call data to ensure health administration services staff at the Atlanta facility who answer calls for the mental health and specialty care clinics meet Veterans Health Administration call center performance standards for timeliness and abandonment rate.

The Greater Los Angeles Healthcare System Director ensures veterans enrolled in the Housing and Urban Development Veterans Affairs Supportive Housing program have documented treatment plans consistent with Veterans Health Administration and facility policy.

The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors’ electronic health record review process to assess Housing and Urban Development Veterans Affairs Supportive Housing-related documentation, including treatment plan deficiencies, and takes action as warranted.

The Greater Los Angeles Healthcare System Director ensures facility Housing and Urban Development Veterans Affairs Supportive Housing program discharge policy is in alignment with Veterans Health Administration policy.

The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors’ process to identify incongruencies between electronic health records and Homeless Operations Management and Evaluation System documentation, and takes action as warranted.

The Greater Los Angeles Healthcare System Director reviews patient aligned care team assignments for unhoused Housing and Urban Development Veterans Affairs Supportive Housing veterans, and takes action as warranted.

The VA Montana Healthcare System Director reviews Community Living Center physician coverage to identify barriers and gaps, determines options for resolution, and completes and executes a coverage plan to ensure residents’ care and staff’s needs are met when the physician is not available for extended periods.

The VA Montana Healthcare System Director reviews Community Living Center physical therapy staffing to identify barriers and gaps, determines options for resolution, and completes and executes a hiring plan to ensure residents’ care and staff’s needs are met.

The Carl T. Hayden Medical Center Director ensures that supervisory staff take effective actions to correct clinical deficiencies.

The Carl T. Hayden Medical Center Director identifies electronic health records containing the dermatologist’s misuse of copy and paste and takes action as warranted to ensure the safety of patients.

The Carl T. Hayden Medical Center Director ensures that service chiefs and patient safety staff report instances of misuse of copy and paste to Health Information Management System staff.

The Carl T. Hayden Medical Center Director ensures a comprehensive review is conducted to determine if the dermatologist documented electrodesiccation and curettage procedures that were not performed and takes action as warranted, including providing patients with clinical care and disclosures if needed, and notifying the Office of Inspector General.

The Carl T. Hayden Medical Center Director ensures that the Chief of Staff is aware of and addresses pervasive deficiencies, when they exist, in clinical care provided at the facility.

The Desert Pacific Healthcare System Network Director evaluates reasons for noncompliance with the state licensing board reporting policy with regard to the dermatologist, and takes action as needed.

The Carl T. Hayden Medical Center Director ensures that a dermatologist conducts a review of the dermatologist’s patients with consideration of the concerns laid out in this report, to identify patients who may need follow-up care and disclosures, and takes action as warranted.

The Carl T. Hayden Medical Center Director reviews with facility leaders, disclosure requirements outlined in VHA Directive 1004.08, Disclosure of Adverse Events to Patients.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

The Veteran Integrated Service Network Director, in conjunction with facility directors, ensures facility staff scan all community care documents into the patient’s electronic health record within five business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain medical documentation prior to administratively closing consults.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative closure of consults that are not low risk.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff schedule patients for community care appointments within seven days of consult entry or receipt in the department.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended scheduled community care appointments and received care.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per calendar year.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff complete the operating model staffing tool reassessment every 90 days.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures VHA staff scan all community care documents into the patient’s electronic health record within five business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff attach diagnostic imaging results to the Community Care Consult Result note.

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative consult closure.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate requests for additional services and supporting medical documentation in patients’ electronic health records.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff verify community care providers’ signatures on requests for additional services forms.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send letters to community providers when they deny requests for additional services.