All Reports

The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.

The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.

The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.

The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.

The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.

The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.

The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.

The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.

The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.

The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.

The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.

Update VA’s Adjudication Procedures Manual on when personnel should request medical disability examinations and opinions.

Reduce examination and medical opinion overdevelopment by establishing a plan to continue the development of examination request tools and evaluate the effectiveness of these efforts for any future enhancements.

Correct the two errors involving prematurely denied Dependency and Indemnity Compensation claims.

Conduct a file review of the reopened Dependency and Indemnity Compensation claims granted under the PACT Act from January 1 through August 31, 2023, and take appropriate actions to ensure monetary benefits and notification letters are accurate.

Consider whether modifications could be made to the reevaluation request process consistent with the PACT Act and related regulations and, should this result in a policy change, consult with the VA Office of General Counsel.

The Under Secretary for Health ensures Veterans Health Administration leaders assess reasons for noncompliance with training requirements and takes action as warranted.

The Under Secretary for Health evaluates whether toxic exposure screening is negatively affecting primary care workload and takes action to mitigate as needed.

Implement and periodically monitor the effectiveness of a plan to provide oversight for unsent packages in the Package Manager application.

Implement a plan to address existing unsent packages in the Package Manager application.

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

Implement a more effective system life-cycle process to ensure network devices are running authorized software and operating systems that are configured to approved baselines and free of vulnerabilities.

Ensure all file systems holding veteran information are encrypted in accordance with NIST and VA policy requirements.

Maintain an accurate inventory of personnel with key access to the facility.

Enable improved audit logging capability to monitor administrator access to sensitive information hosted on the Workload Reporting and Productivity Assessing file server.

The Richmond VA Medical Center Director ensures completion of a clinical review of patient 2’s cardiothoracic surgical episode of care and takes action as appropriate.

The Under Secretary for Health ensures that consideration to reactivate the heart transplant program at the Richmond VA Medical Center includes a comprehensive analysis of transplant referral volume, leadership competency, and transplant team proficiency.

The Under Secretary for Health ensures that VA Mid-Atlantic Health Care Network and Richmond VA Medical Center leaders conduct a rigorous surveillance of quality measures if the heart transplant program is reactivated and emphasize safely meeting program target volumes to maintain clinical experience.

The Richmond VA Medical Center Director ensures the chief of surgery conducts a review of the cardiothoracic section chief’s unprofessional behaviors and develops a plan to address complaints.

The Richmond VA Medical Center Director ensures surgical leaders review cardiothoracic staff’s concerns and take action to create a culture of safety, and considers the use of resources such as the National Center for Organization Development.

The VA Mid-Atlantic Health Care Network Director develops a process for ensuring VA Mid-Atlantic Health Care Network staff provide timely and complete responses to facility leaders’ requests for clinical care reviews.

Execute the compliance plan for the Veterans Benefits Administration’s personnel suitability program.

Ensure the Veteran Benefits Administration’s personnel suitability program oversight verifies background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Establish a plan to ensure robust oversight of the National Cemetery Administration’s personnel suitability program that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Evaluate resource requirements for the personnel suitability program to ensure that all personnel suitability requirements are being met.

District leaders and the Everett and Walla Walla 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 Eugene Vet Center Director 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 Anchorage, Eugene, and Everett 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 Anchorage, Eugene, Everett, and Walla Walla 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 Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.

District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Eugene Vet Center Director determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors and ensure compliance with the requirement.

District leaders and the Eugene and Walla Walla Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

District leaders and the Kauai Vet Center Director determine reasons for noncompliance with assigning a licensed mental health professional as a clinical liaison, ensure a process is implemented, and monitor compliance.

District leaders and the Corona, Temecula, Kauai, and Western Oahu 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 Western Oahu 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 Corona, Temecula, Kauai, and Western Oahu 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 Western Oahu Vet Center Director determine reasons for noncompliance with completion of a current written outreach plan, ensure completion, and monitor compliance.

The District Director and zone leaders, in conjunction with the Corona, Temecula, and Kauai 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 Western Oahu Vet Center Director determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.

District leaders and the Corona, Temecula, and Western Oahu Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

District leaders and the Temecula and Western Oahu Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Temecula Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.

District leaders and the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Kauai and Western Oahu Vet Center Directors determine reasons for noncompliance with having an updated emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

District leaders and the Phoenix and West Valley Vet Center Director 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 Antelope Valley, Phoenix, and West Valley 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 West Valley 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 Antelope Valley Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.

District leaders and the Antelope Valley, Phoenix, Santa Fe, and West Valley 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 Santa Fe Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.

District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.

District leaders and the Phoenix and Santa Fe Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.

District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.

The New York/New Jersey VA Health Care Network Director conducts a review of system leaders’ responses to repeated concerns regarding delayed community care consult scheduling for patients with serious health conditions to determine whether leaders’ actions were in alignment with patient safety and high reliability organizational principles, and take action as warranted.

The New York/New Jersey VA Health Care Network Director ensures VA Western New York Health Care System Director develops community care consult practices and procedures for managing consults deemed high-risk or complex, implements an effective process to ensure consistency with processing consults within Veterans Health Administration timeliness requirements, and audits for compliance.

The VA Western New York Health Care System Director ensures system community care leaders develop and implement standardized operating procedures for consult management consistent with Veterans Health Administration standards, provide training to community care staff, monitor compliance, and evaluate effectiveness.

The VA Western New York Health Care System Director ensures all efforts to conduct an institutional disclosure to Patient A’s family are made and that the disclosure is documented in the patient’s electronic health record, as required.

The VA Tuscaloosa Healthcare System Director conducts a full review of care provided to the patient by clinical staff, consults with Human Resources and General Counsel Offices, and takes action as needed.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure that providers provide patient education about applicable boxed warnings when prescribing psychiatric medication, and monitors compliance.

The VA Tuscaloosa Healthcare System Director ensures mental health staff conduct suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates outpatient mental health clinic scheduling procedures; identifies barriers to timely appointment scheduling, including staffing levels; and takes action as warranted.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adequate lethal means assessment and lethal means safety counseling with patients.

The VA Tuscaloosa Healthcare System Director reviews posttraumatic stress disorder clinic processes to consult with a patient’s prescriber following worsening of a patient’s mental health symptoms.

The VA Tuscaloosa Healthcare System Director ensures posttraumatic stress disorder clinic consult and documentation procedures align with Veterans Health Administration requirements.

The VA Tuscaloosa Healthcare System Director conducts a review of the supervisory oversight of the social worker and other clinicians in the posttraumatic stress disorder clinic to ensure the identification and follow-up of clinical concerns for patients with complex mental health needs.

The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adherence to Veterans Health Administration and facility traumatic brain injury screening and consult requirements, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates the root cause analysis processes regarding reporting of incomplete action items in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The VA Tuscaloosa Healthcare System Director evaluates the Peer Review Committee processes on addressing identified system issues in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.

The Under Secretary for Health considers establishing written guidance regarding the Behavioral Health Autopsy Program family interview process, including suicide prevention program staff’s consultation, to ensure that the decision to not outreach a family member is based on the best interest of the family.

The VA Tuscaloosa Healthcare System Director ensures compliance with the Behavioral Health Autopsy Program including completion of the Family Interview Tool-Contact Form.

The VA Tuscaloosa Healthcare System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.

The VA Augusta Health Care System Director ensures that the Mental Health Executive Council includes veteran representation.

The Veterans Integrated Service Network Director implements processes to strengthen oversight and monitoring of bed utilization.

The VA Augusta Health Care System Associate Director for Patient Care Services ensures that inpatient mental health unit staffing supports authorized bed capacity.

The VA Augusta Health Care System Director develops and implements processes to incorporate veteran input for process improvements.

The VA Augusta Health Care System Chief of Mental Health develops processes to ensure integration of the Local Recovery Coordinator into the inpatient mental health unit to support recovery-oriented care.

The VA Augusta Health Care System Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures continued implementation of a recovery-oriented environment on the inpatient mental health unit.

The VA Augusta Health Care System Director ensures accurate reporting of inpatient operating beds and implements processes to monitor.

The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.

The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.

The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans’ voluntary or involuntary legal status, consistent with VHA policy and state laws.

The VA Augusta Health Care 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 improvement.

The VA Augusta Health Care System Director ensures the development and implementation of clearly defined written processes for transition of care when veterans are discharged from the inpatient mental health unit.

The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.

The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.

The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.

The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.

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

The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.

The VA Augusta Health Care System Director ensures compliance with VHA requirements for the Interdisciplinary Safety Inspection Team, including environment of care subcommittee structure, and Mental Health Environment of Care Checklist training completion.

The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.

Ensure the Network Contracting Office 12 contracting officer develops a cardiothoracic services contract solution that meets the Medical Sharing/Affiliate National Program Office threshold for review.

Establish procedures to regularly identify and review healthcare resources contracts that have been modified resulting in contract values that exceed the threshold and determine if any further action by Regional Procurement Office Central leaders or the head of contracting activity is necessary.

Ensure the Network Contracting Office 12 contracting officer makes the sole-source contract justifications publicly available as required.

Ensure corrective actions are taken to resolve the issues identified in the Medical Sharing/Affiliate National Program Office fact-finding investigation.

Establish and implement guidance for quality assurance measures over the data used to develop and justify the ambulatory care budget estimate.

Ensure the deputy under secretary for health provides oversight and holds the Office of Finance accountable for developing, documenting, and implementing standard operating procedures to include defining roles and responsibilities and requirements for oversight and quality assurance for development of the ambulatory care budget estimate.

Implement the Veterans Health Administration Data Governance Council, to include developing policies and processes for data management across the Veterans Health Administration.

Ensure the Veterans Health Administration Data Governance Council identifies authoritative data sources and nominates data stewards for approval by the VA Data Governance Council.

Coordinate with the Health Administration Service chief to develop local policy and standard operating procedures to ensure wheelchair-accessible transportation service invoices are adequately reviewed before certification for payment in accordance with financial policy and contract documentation.

Recover approximately $3.7 million from the contractor for transportation overcharges.