All Reports

Track facilities’ supply chain personnel vacancies as part of the quality control reviews and take appropriate action.

Develop guidelines that define when facility supply chain management problems require additional interventions and then routinely identify them for network director action.

Ensure facility and network directors work with the Procurement and Logistics Office on a plan to identify resources and milestones to resolve identified supply chain management problems for identified facilities.

Direct the program office to develop a process to provide resources when needed to help networks and facilities resolve persistent supply chain management deficiencies, including those identified in this report.

Continue Procurement and Logistics Office efforts to automate tracking that will accurately capture and monitor all quality control review results, corrective action plans, and implementation of those plans.

Update the Procurement and Logistics Office audits of the quality control program to apply risk‑based sampling, evaluate action plan sufficiency and implementation, and use the results to continuously improve quality control review guidance and requirements.

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

Consider a plan to align VA Pittsburgh Healthcare System financial management practices with federal financial accounting standard practices, which could include using cost information for performance measurement, budgeting, cost control, and making economic decisions.

Ensure requesting offices are trained to effectively communicate status of open obligations in a timely manner so healthcare system finance staff can comply with VA Financial Policy, vol. 2, chap. 5, “Obligation.” by ensuring monthly that open obligations balances are valid and should remain open or are closed in a timely manner.

Establish an escalation process to notify the appropriate leaders if the requesting office does not provide a response to the finance office’s monthly request for status of outstanding obligations.

Establish controls to confirm approving officials and cardholders review purchases for VA policy compliance, ensuring purchases are not being split and that strategic sourcing is pursued for ongoing or repetitive purchases.

Ensure supply chain managers implement a plan to detect and correct data validity issues within inventory systems.

Improve vulnerability management processes to ensure plans of action and milestones are created for vulnerabilities that cannot be mitigated within OIT timelines.

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

Implement a process to verify that when employees are terminated, all their accounts are disabled.

Ensure network segmentation controls are applied to all network segments with special-purpose systems.

Implement a process to retain database logs for a period consistent with VA’s record retention policy.

Instruct the Office of Finance to review the $14 million retained by the medical centers to ensure these funds were, or will be, spent in accordance with all applicable VA policies and federal laws.

Require the Office of Finance to strengthen controls over designated specific purpose funds so that Veterans Integrated Service Network chief financial officers can account for all the distributed funds and make certain that the funds are used for the intended purpose.

Define the roles and responsibilities of the appropriate assistant under secretaries, program office staff, and regional and medical center staff in the implementation and monitoring of the substance use disorder hiring initiative and ensure the relative priority of the initiative is communicated; hiring progress is monitored; possible hiring challenges are addressed to the extent possible; and actions are taken as needed to meet the goals of the hiring initiative.

Establish internal controls to help ensure the healthcare system monitors the Medical/Surgical Prime Vendor product list for updates and completes the item conversion process

Ensure that prime vendor contract performance issues are routinely reported to the Medical Supplies Program Office and the Strategic Acquisition Center using established Veterans Health Administration reporting tools.

In coordination with the Strategic Acquisition Center, submit ratifications for any unauthorized commitments following the Federal Acquisition Regulation.

Ensure that the facility-level contracting officer’s representative and ordering officers are appointed and delegated properly and perform all required duties according to the scope and limitation of the designee’s authority.

Establish internal controls to help ensure the healthcare system submits national contract requests for waiver and justifications prior to purchasing available product list items from nonmandatory procurement instruments.

Ensure cardholders obtain a proper prior approval and maintain segregation of duties, and ensure that cardholders and approving officials perform prompt purchase card reconciliations as required by VA financial policy.

Develop formalized processes and controls to ensure approving officials, cardholders, and the agency contracting office review repetitive open market purchases of goods and services and obtain contracts when it is determined to be in the best interest of the government.

In coordination with the Strategic Acquisition Center, submit a ratification for an unauthorized commitment following the Federal Acquisition Regulation.

Develop formalized processes for monitoring and achieving efficiency targets and using available pharmacy data to make business decisions.

Develop and implement a plan to increase inventory turnover to meet or exceed the VHA-recommended level, and complete monthly B09 reconciliations consistently to ensure discrepancies are corrected in a timely manner.

Establish measures to improve compliance with the VA directive to avoid end-of-year pharmaceutical purchases.

The VA Black Hills Health Care System Director ensures that summary suspensions and related privileging actions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.

The VA Black Hills Health Care System Director in conjunction with facility leaders and surgical service leaders, ensures a focused clinical care review is completed of the care provided by the subject provider according to Veterans Health Administration policy, and takes action as warranted.

The VA Black Hills Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates the patient safety event reporting processes, identifies deficiencies, and takes action as warranted to ensure compliance with entering adverse events or close calls into the Joint Patient Safety Reporting system.

The VA North Florida/South Georgia Health System Director consults with the Office of General Counsel to ensure system and service line policies and practices related to voluntary and involuntary admissions under the Baker Act provide clear guidance and are consistent with Florida state law as allowed by federal law and Veterans Health Administration regulations.

The VA North Florida/South Georgia Health System Director ensures that providers document their rationales for initiating involuntary examinations under the Baker Act within a patient’s electronic health record and monitors compliance.

The VA North Florida/South Georgia Health System Director verifies that a process is in place to provide patients who are admitted for an involuntary examination under the Baker Act with written information on their rights and monitors compliance.

The VA North Florida/South Georgia Health System Director confirms that mental health staff document offering evidence-based therapies during treatment planning with patients diagnosed with posttraumatic stress disorder, as required by Veterans Health Administration policy, and monitors compliance.

The VA North Florida/South Georgia Health System Director ensures that all licensed mental health staff receive annual training on the Baker Act and tracks compliance.

The VA North Florida/South Georgia Health System Director determines if there is a need for non-mental health providers in the emergency department to complete Baker Act training and takes action as warranted.

The VA North Florida/South Georgia Health System Director, in consultation with Veterans Health Administration’s Senior Security Officer, ensures system police, emergency department, and mental health staff follow VA policy specific to assisting staff in the prevention of patient elopements prior to an involuntary mental health evaluation and tracks compliance.

The VA North Florida/South Georgia Health System Director develops a process to provide oversight of compliance with all elements required by state law for use of the Baker Act as permitted by federal law and Veterans Health Administration policy.

The VA North Florida/South Georgia Health System Director, in consultation with the Office of General Counsel, determines whether Baker Act reporting by the system is required and provides clear guidance for applicable reporting processes.

The VA North Florida/South Georgia Health System Director develops a process to ensure system policies adhere to Veterans Health Administration Directive 0999(1), medical center policy standardized template as it pertains to assignment of oversight responsibilities.

The VA North Florida/South Georgia Health System Director directs a review of current patient advocate processes for follow-up and resolution with complainants, updates the process as warranted, and monitors compliance.

The VA North Florida/South Georgia Health System Director considers having the patient advocate process for tracking and monitoring trends capture complaints specific to involuntary admissions for leaders’ awareness and follow-up.

Establish a mechanism to monitor progress of the Digital GI Bill platform implementation under the renegotiated contract to avoid additional costs and delays.

Communicate regularly with the Digital GI Bill platform contractor to ensure that the project’s integrated master schedule or other master scheduling plan is consistently updated to reflect all schedule changes for external dependencies.

Develop strategies to address critical path failures to provide a clear timeline of further implementation activities.

District leaders and the Jackson and Corpus Christi 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 Fort Worth Vet Center Director determine reasons for noncompliance with Readjustment Counseling Service documentation standards, ensure completion, and monitor compliance.

District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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 Jackson and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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 Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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 Fayetteville 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 New Orleans Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

District leaders and the New Orleans, Jackson, and Corpus Christi Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Fayetteville and Fort Worth 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 Fayetteville, Corpus Christi, Fort Worth, and San Antonio Northeast 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 Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne 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 Fort Collins, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Fort Collins, Abilene, and Salt Lake City Vet Centers Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.

District leaders and the Fort Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Fort Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Cheyenne Vet Center Director determine reasons for noncompliance with completion of an annual fire or safety inspection, ensure completion, and monitor compliance.

District leaders and the Abilene and Cheyenne 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 Fort Collins and Kalispell Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.

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

District leaders and the Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.

District leaders and the Salt Lake City Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.

District leaders and the Cheyenne Vet Center Director determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors, ensure completion, and monitor compliance.

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

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 assesses 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 that a safety plan was provided to all active clients assessed at intermediate or high suicide risk levels, and monitors compliance across all zone vet centers

The Veterans Crisis Line Director determines the optimal ratio of supervisors to frontline staff needed, makes the best efforts to ensure the ratio is maintained, and takes action as warranted.

The Veterans Crisis Line Director ensures supervisors and staff are aware of postvention resources and monitors for compliance.

The Veterans Integrated Service Network Director ensures thorough completion of the VA Central Western Massachusetts Healthcare System pharmacy corrective actions, and takes action as needed.

The Veterans Integrated Service Network Director ensures that pharmacy supervisors and staff at the VA Central Western Massachusetts Healthcare System receive the necessary training and written guidance to complete the corrective actions, and monitors for compliance.

The Veterans Integrated Service Network Director ensures that leaders, whose actions contributed to the incomplete corrective actions and ineffective oversight, receive administrative action, as appropriate.

Require the Office of Integrated Veteran Care and Pharmacy Benefits Management Services to improve community provider compliance when prescribing special-authorization drugs and being responsive to VA pharmacy inquiries. This should include consideration of electronic system capabilities to attach medical justifications, allow community providers to have real-time access to VA’s formulary when prescribing drugs, and enable two-way communication between community providers and VA pharmacists electronically.

Task the Office of Integrated Veteran Care to train community providers on the VA formulary and implement a process to improve tracking of training completion and community providers’ compliance with VA guidance on submitting prescriptions for special-authorization drugs.

Direct Pharmacy Benefits Management Services to update its dashboard to more accurately capture special-authorization drug request processing times and provide the Office of Integrated Veteran Care access to this information for contract management purposes.

Instruct Pharmacy Benefits Management Services to require that VA pharmacy personnel document community care prescriptions for special-authorization drugs in the veteran’s medical record (in consults when applicable or medical notes) when the pharmacy receives the prescription and make clear that the 96-hour processing time is a requirement for these types of drug requests.

Require Pharmacy Benefits Management Services to routinely remind pharmacists that they are responsible for reporting a community provider to the medical facility’s community care office when the provider does not comply with VA documentation requirements for special-authorization drug requests.

Charge facility community care offices to work with pharmacy personnel to report when they receive information from VA pharmacists that community providers did not comply with VA’s documentation requirements for special-authorization drugs. Reporting mechanisms can include submitting Potential Quality Issue Referral reports or Health Care Quality Concern reports to third-party administrators.

Direct Pharmacy Benefits Management Services to standardize requirements for how VA pharmacists code drug requests from community providers in the electronic system that were canceled, rejected, or removed to help VHA determine if corrective actions need to be taken on processes, contract terms, or guidance.