All Reports

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.

The OIG recommends facility leaders relocate papers and folders outside of patient examination rooms or secure them in protective coverings to mitigate the risk of infection.

Complete level 1 summary reports for the Pension and Fiduciary Service fiscal year 2023 PACT Act training courses and provide feedback from the reports to training staff.

Establish a plan to conduct all four levels of evaluation for PACT Act training and provide feedback to training staff.

Establish deadlines in training evaluation plans for the creation of summary reports.

The OIG recommends the Veterans Integrated Service Network Director takes actions to ensure stable and consistent leadership at the facility.

The OIG also recommends Veterans Integrated Service Network leaders assist facility leaders to improve interactions with local union leaders.

The OIG recommends the Interim Medical Center Director ensures all security cameras are operational.

The OIG recommends the Interim Medical Center Director ensures primary care teams are staffed according to Veterans Health Administration guidelines.

The OIG recommends facility leaders ensure staff understand procedures for cleaning equipment and continue to monitor the physical separation of clean and dirty items in storage spaces.

The OIG recommends that primary care leaders incorporate feedback from primary care staff and include them in process improvement projects.

The District Director, in conjunction with the Deputy District Director, develops a contingency coverage plan to ensure oversight during periods of vet center director vacancies.

The District Director monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.

The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including panel member assignments, participation of affected vet center staff, report completion, reporting of completion delays, and information dissemination.

The District Director determines reasons vet center counselors did not complete safety plan components for clients assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures completion of safety plans for all active clients assessed at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.

The District Director determines reasons staff did not document providing safety plans to clients, ensures all active clients assessed at intermediate or high suicide risk levels receives a safety plan, and monitors compliance across all zone vet centers.

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.