All Reports

The Facility Director establishes a mental health executive council that operates in accordance with Veterans Health Administration requirements.

The Facility Director ensures development and implementation of a multi-year recovery transformation plan.

The Associate Chief of Staff for Behavioral Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekdays and weekends on the inpatient mental health units.

The Facility Director ensures inpatient mental health units are in good repair and the environment reflects recovery-oriented principles.

The Facility Director ensures veterans’ privacy in restraint rooms on the inpatient mental health units.

The Associate Chief of Staff for Behavioral Health develops written guidance to ensure staff and veterans’ safety during outdoor breaks.

The Facility Director formalizes processes to monitor and track compliance with state involuntary commitment laws.

The Chief of Staff ensures the completion of comprehensive inpatient mental health treatment plans and monitors for compliance.

The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures mental health treatment coordinators are included in care coordination.

The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.

The Chief of Staff ensures discharge instructions for veterans include the purpose for each listed medication in easy-to-understand language.

The Chief of Staff ensures discharge instructions for veterans include an explanation when both trade and generic names are used for the same medication.

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

The Chief of Staff ensures safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.

The Facility Director ensures staff comply with timely completion of VA S.A.V.E. training requirements and monitors for compliance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including recording meeting minutes and including all required members, and monitors for compliance.

The Facility Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards within the Patient Safety Assessment Tool and monitors for compliance.

The Facility Director ensures staff address identified Mental Health Environment of Care Checklist deficiencies in accordance with Veterans Health Administration guidelines and monitors for compliance.

The Facility Director ensures Interdisciplinary Safety Inspection Team members comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.

The Facility Director ensures the mental health executive council operates in accordance with VHA requirements.

The Chief of Mental Health identifies barriers and implements processes to provide a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit and monitors for compliance.

The Facility Director develops and implements processes to monitor and track compliance with involuntary commitment requirements. 

The Chief of Staff ensures timely documentation of informed consent discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.

The Chief of Staff ensures discharge instructions for veterans are written in easy-to-understand language and include the purpose for each medication. 

The Chief of Staff directs staff to complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The Chief of Staff directs staff to complete or review safety plans with veterans prior to discharge and monitors for compliance. 

The Chief of Staff directs staff to address ways to make the veteran’s environment safer from potentially lethal means in safety plans and monitors for compliance. 

The Facility Director directs staff to comply with Lethal Means Safety training and monitors for compliance. 

The Facility Director directs staff to comply with Skills Training for Evaluation and Management of Suicide training and monitors for compliance. 

The Facility Director directs staff to comply with VA S.A.V.E. training and monitors for compliance. 

The Facility Director ensures Interdisciplinary Safety Inspection Team requirements are met and monitors for compliance. 

The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards to all sections on the inpatient mental health unit and monitors for compliance. 

The Facility Director uses VHA guidelines to develop a facility-specific policy for the use of restraint chairs. 

The Facility Director directs staff to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance. 

We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the National Institute of Standards and Technology (NIST) Risk Management Framework (RMF). Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions.

We recommended the Assistant Secretary for Information and Technology implement improved processes for reviewing and updating key security documentation, including Security Control Assessments, Risk Assessments, and Privacy Impact Assessments as needed. Such updates will ensure all required information is included and accurately reflects the current environment, new security risks, and applicable federal standards.

We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure System Security Plans reflect the status of security control implementations and risks are accurately reported to support a comprehensive risk management program across the organization.

We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system owners and information system security officers follow procedures for establishing, tracking, and updating POA&Ms for all known risks and weaknesses including those identified during security control and other assessments.

We recommended the Assistant Secretary for Information and Technology implement measures to ensure that system stewards and other officials responsible for system level POA&Ms are closing items with relevant support that shows sufficient remediation of the identified weakness.

We recommended the VA Office of Personnel Security, Human Resources, and Contract Offices strengthen processes to ensure appropriate levels of background investigations are performed timely and completed for applicable VA employees and contractors.

We recommended the Office of Personnel Security, Human Resources, and Contract Offices implement improved processes for establishing and maintaining accurate investigation data within VA systems used for background investigations.

We recommended the Assistant Secretary for Information and Technology ensure contingency plans for all systems and applications are updated and tested in accordance with VA requirements.

We recommended the Assistant Secretary for Information and Technology implement improved procedures to ensure that system outages are resolved within stated recovery time objectives.

We recommended the Assistant Secretary for Information and Technology ensure system owners consistently implement processes for periodic reviews of user account access. Remove unnecessary and inactive accounts on systems and networks.

We recommend the Assistant Secretary for Information and Technology coordinate with system owners and local system management to ensure the consistent monitoring and reviewing of privileged accounts, service accounts, and accounts for individuals with access to source code repositories are performed across VA systems and platforms.

We recommend the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security configuration baselines on domain controllers, operating systems, databases, application, and network devices.

We recommended the Assistant Secretary for Information and Technology ensure established change control procedures are consistently followed for testing and approval of system changes for VA applications and networks.

We recommended the Assistant Secretary for Information and Technology implement and consistently enforce established procedures for preventing and detecting potential unauthorized changes across all platforms and applications in the environment.

We recommended the Assistant Secretary for Information and Technology ensure that all systems and platforms are monitored for compliance with documented VA standards for baseline configurations. Ensure that system owners consistently implement and monitor their configurations.

We recommended the Assistant Secretary for Information and Technology implement automated software management processes on all agency platforms to identify and prevent the use of unauthorized software on agency devices.

We recommended the Assistant Secretary for Information and Technology implement improved procedures for establishing, documenting, and monitoring an accurate software and logical hardware inventory for system boundaries across the enterprise.

We recommended the Assistant Secretary for Information and Technology implement improved processes for monitoring and analyzing significant system audit events for unauthorized or unusual activities across all systems and platforms in accordance with VA policy. Ensure privileged activity is monitored on all systems and applications.

We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise.

We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and Web application servers in accordance with established policy timeframes. If patches cannot be applied or are unavailable, other protections or mitigations should be documented and implemented to address the specific risks.

We recommended the Assistant Secretary for Information and Technology continue to implement improved segmentation controls that restrict vulnerable medical devices from unnecessary access from the general network.

We recommended the Assistant Secretary for Information and Technology implement improved processes to require system owners and management to provide adequate credentials to ensure security scans are authenticated to end devices where feasible and the subsequent vulnerabilities are remediated in a timely manner.

We recommended the Assistant Secretary for Information and Technology improve the process for tracking and resolving vulnerabilities that cannot be addressed by enterprise processes within policy timeframes. Implement mitigations for identified security deficiencies by applying security patches, system software updates, or configuration changes to reduce applicable security risks.

The OIG recommends the facility Director ensures leaders provide a safe and clean environment of care for veterans, including having adequate staff to clean floors, protecting patient information, and ensuring food is dated and has not expired.

The OIG recommends facility leaders develop and implement a plan to resolve infrastructure issues that affect patient care.

The OIG recommends facility leaders develop and implement a plan to resolve veterans’ unanswered phone calls and inability to reach staff.

The OIG recommends facility leaders replace the emergency call boxes in the parking garage to ensure they are active and functioning.

The OIG recommends facility leaders update local policies and memorandums related to communication of test results.

The OIG recommends the Director ensures the Chief of Staff conducts institutional disclosures for applicable adverse events.

The OIG recommends facility leaders take additional actions to obtain manageable panel sizes per VHA guidelines and ensure patients have access to high-quality care.

The OIG recommends facility leaders evaluate and improve processes for medical clearance of veterans who participate in the Compensated Work Therapy program.

Establish internal control procedures to ensure recruitment, relocation, and retention incentive documentation is appropriately maintained in accordance with VA policy and guidance.

Enforce procedures to ensure Veterans Integrated Service Network human resources offices properly review recruitment, relocation, and retention incentive documentation for compliance with VA policy.

Enforce quality control checks to ensure Veterans Integrated Service Networks fulfill requirements for maintaining recruitment, relocation, and retention incentives documentation.

Establish accountability measures to ensure Veterans Integrated Service Networks’ quality control and oversight responsibilities are risk-based and fulfilled in a timely manner.

Evaluate resource requirements and establish accountability measures to ensure quality control and oversight responsibilities are risk-based and fulfilled in a timely manner.

Evaluate the retention incentive awards for the 28 employees identified in this report who received payments after the incentive period ended, terminate the incentive if it was not recertified, determine whether recoupment of funds is warranted, and take action if appropriate.

Assess retention incentive payment data to identify awards that have been paid for over one year and determine whether each has been appropriately recertified or should be terminated.

Establish oversight procedures to ensure retention incentives are reviewed annually, recertified if appropriate, or otherwise terminated to ensure payments are not continued after the expiration date.

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.

Ensure all erroneous scenarios in the Veterans Benefits Management System for Rating special monthly compensation calculator identified in this review are corrected and certify the results to the VA Office of Inspector General.

Establish a plan to conduct additional testing of the Veterans Benefits Management System for Rating special monthly compensation calculator to ensure its accuracy.

Update the Fiduciary Program Manual to specify when a removed fiduciary should be flagged as “Do Not Appoint” and ensuring that staff understand if they are responsible for adding the flag.

Develop and provide training on updated Fiduciary Program Manual procedures on flagging barred individuals or entities as “Do Not Appoint” and include a mechanism to ensure that fiduciary hub staff have taken and understand the training.

Update the quality review process to include ensuring that fiduciaries are flagged “Do Not Appoint” when required.

Instruct the program to communicate pertinent annual funding guidance related to Pain Management, Opioid Safety, and Prescription Drug Monitoring Program initiatives before the start of the upcoming fiscal years so that Veterans Integrated Service Networks and medical facilities can adequately plan and take appropriate hiring actions needed to spend their funds.

Ensure the program communicates pertinent funding information related to Pain Management, Opioid Safety, and Prescription Drug Monitoring Program initiatives with key personnel—such as program coordinators and Veterans Integrated Service Network and medical facility leaders.

Ensure the program clarifies and defines requirements for pain management teams in the new Veterans Health Administration Directive 1151, Pain Management and Opioid Safety.

Establish means to periodically validate the status information of facilities’ pain management teams.

Require the program and the chief operating officer to assess and ensure corrective actions are taken to address each medical facility’s lack of progress in achieving compliance with the requirement to have a pain management team as mandated by the Jason Simcakoski Memorial and Promise Act.

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.

District leaders and the Evanston, La Crosse, and Milwaukee 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 Evanston, Gary Area, La Crosse, and Milwaukee 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 Gary Area 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 Gary Area, La Crosse, and Milwaukee 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 Evanston, Gary Area, and Milwaukee 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 the La Crosse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders determine reasons why the closing of the Milwaukee Vet Center resulted in multiple communication failures, and ensure all clients are notified of the new location, the Vet Center Call Center has accurate information, and websites include correct location and phone number information.

The Readjustment Counseling Service Chief Officer considers developing written guidance for vet center closure and temporary relocation processes including oversight responsibilities.

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 Martinsburg VA Medical Center Director reviews communication between emergency department staff to ensure timely patient care coordination, and takes action as warranted.

The Martinsburg VA Medical Center Director ensures emergency department nurses monitor, assess, and document patient care as required by Veterans Health Administration and Martinsburg VA Medical Center policy, and monitors compliance.

The Martinsburg VA Medical Center Director ensures processes are in place to ensure blood transfusions are administered according to policy, and monitors compliance.

The Martinsburg VA Medical Center Director conducts a review of actions implemented as a result of the factfinding to include administrative actions and performance improvement plans and ensures quality of care concerns have been remediated, and takes action as warranted.

The Martinsburg VA Medical Center Director evaluates the functionality of emergency room equipment, including an exam table with footrests, for conducting gynecologic examinations with dignity and comfort, and takes action as warranted.

The Martinsburg VA Medical Center Director reviews concerns related to fire department overtime practices, takes action as appropriate, and follows up to ensure compliance.

The Martinsburg VA Medical Center Director reviews the transport delay for the abdominal pain patient, and takes action as appropriate.

The Martinsburg VA Medical Center Director reviews the factfinding related to transportation concerns, ensures an adequate review is conducted, and takes action as warranted.

The Martinsburg VA Medical Center Director ensures all reported patient safety concerns related to emergency transport delays are investigated to identify root causes and contributing factors that require action to prevent future events.

The Martinsburg VA Medical Center Director ensures clear guidance is in place for clinical and administrative staff on the use of facility emergent and non-emergent transport resources.

Reduce improper and unknown payments to below 10 percent for the Pension Program.

Reduce improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program.

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.

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

Implement a more effective baseline configuration process to ensure network devices are running authorized software that is configured to approved baselines and free of vulnerabilities.

Improve the remediations reporting process for the Continuous Readiness in Information Security Program to verify that corrective actions are taken to fully mitigate vulnerabilities for biomedical devices at the Battle Creek facility.

Implement improved physical access controls to restrict access to the server room and communications closets.

Ensure network segmentation controls are applied to all network segments hosting special-purpose systems or medical devices.

Implement improved, consistent environmental controls for network communications closets.

The Veterans Health Administration chief operating officer establishes a written policy or procedure to reasonably ensure that potential conflicts of interest or appearance of partiality concerns involving VHA employees are identified and remediated before contractor presentations to Veterans Integrated Service Network or facility leaders. 

The Veterans Integrated Service Network 8 director confirms that VA has initiated the process to seek recoupment of the critical skill incentive paid by VA to Ms. Skala that was attributable to a service period that she did not complete due to her retirement.

The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness directs a review to determine whether any VHA employee ranked GS‑15 or above awarded a critical skill incentive has left VA before completing their required service obligation, and, if so, whether VA has established a debt and initiated recoupment in the amount of the CSI attributable to the uncompleted period, and takes further corrective actions as warranted.