All Reports

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.

The Overton Brooks VA Medical Center Director reviews and monitors compliance with Veterans Health Administration health professions trainee onboarding requirements, and takes action as indicated.

The Overton Brooks VA Medical Center Director makes certain that oversight of the intensive care unit physician credentialing and privileging process is completed prior to physicians being scheduled and providing patient care, and monitors compliance.

The Overton Brooks VA Medical Center Director ensures root cause analyses are completed according to Veterans Health Administration policy including team composition, root cause analysis process steps, and timeliness.

The Under Secretary for Health evaluates the additional root cause analysis concurrence step used within Veterans Health Administration medical centers to ensure alignment with National Center for Patient Safety guidance, and takes action as indicated.

Incorporate all business-essential processes and related interfaces, as defined by product owners, during validation sessions, user acceptance testing, or equivalent procedures to accurately present system capability.

Enhance the test plan to incorporate a more robust, risk-based testing process that incorporates user-testing requirements for functional and nonfunctional business-essential processes related to interfaces.

Develop a process to confirm with affected administrative offices whether they are aware of needed changes to test environments and that they have sufficiently executed them before interface test events.

Develop a method to evaluate whether test deficiencies necessitate changes to the deployment schedule to ensure deficiencies are properly addressed before wave go-live and implement these changes.

Take corrective actions to ensure that facilities and programs remove unauthorized sensitive information from collaborative application sites.

Direct facilities and programs to standardize SharePoint administration, inventory and consolidate their SharePoint sites, and enforce the recommended architecture to better control access and content at the facility or program level.

Implement enforcement mechanisms to ensure that facilities and programs are following standardized processes to secure SharePoint and Teams sites.

Expand roles and responsibilities of facility and program information system security officers and privacy officers to include the routine review of SharePoint and Teams site permissions and content.

Implement automated tools and policies, supported with training, to enable the timely and routine detection and correction of improper sharing and unauthorized content throughout VA.

Mandate standardized training for SharePoint administrators and owners to clarify and reinforce data security requirements.

The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.

The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.

The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.

The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.

The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.

The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.

Create a job aid for claims processors on how to determine the correct effective date for PACT Act–related claims.

Remove the outdated effective date builder from the Veterans Benefits Administration’s internal job aids page.

Continue updating the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when the Veterans Benefits Administration receives an intent to file.

Update the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when a veteran’s service connection is based on a toxic exposure risk activity.

Evaluate PACT Act refresher training by monitoring the results to assess the effectiveness of the training.

Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.