All Reports

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures Nursing Service staff comply with the cardiac telemetry monitoring policy.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures the medical floor charge nurses create nursing assignments and communicate this information to the telemetry technician and monitors for compliance.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that Intensive Care Unit Service physicians document and complete written responses to critical care consults as required and monitors for compliance.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that the Quality Management and Performance Improvement Service conduct administrative reviews and root cause analyses in accordance with Veterans Affairs and Veterans Health Administration policy and monitors for compliance.

The Lt. Col. Luke Weathers, Jr. VA Medical Center Director consider completion of another root cause analysis to ensure additional system vulnerabilities that may have contributed to this patient event are identified and action plans completed, as applicable, to prevent reoccurrence of similar patient events.

The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by conducting Ongoing Professional Practice Evaluations on a regular basis.

The Medical Center Director ensures the Safety and Occupational Health Specialist or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.

The Medical Center Director ensures staff monitor and document VA police response times to panic alarm testing in the Acute Inpatient Mental Health Unit at least quarterly.

The Medical Center Director ensures the Suicide Prevention Coordinator conducts a minimum of five outreach activities each month.

The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health and quality management leaders.

The Director ensures staff track deficiencies identified during comprehensive environment of care inspections through resolution.

The Director ensures staff maintain a safe and clean environment.

The Under Secretary for Health consider identifying a national program office to be responsible for oversight of alcohol withdrawal management across inpatient settings.

The Under Secretary for Health ensures the identified national program office responsible for oversight of alcohol withdrawal management consider requiring the development and implementation of written guidance for the management of alcohol withdrawal across all inpatient settings, to include: (a) expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; (b) expected actions of nurses to communicate with prescribers based on patients’ changes in symptoms or alcohol withdrawal severity and when that communication should be followed by a prescribers face-to-face evaluation of a patient; (c) expectations for the evaluation of co-occurring conditions, expert consultation, and pharmacotherapy approaches; and (d) expectations for the collection and monitoring of outcome data for inpatient management of alcohol withdrawal at the national and healthcare system level.

The Under Secretary for Health consider the implementation of training for inpatient staff on the administration of standardized alcohol withdrawal severity scales.

The Under Secretary for Health initiates a review of the surgeon’s eligibility to participate in VA’s Community Care Network given Optum’s lack of documentation of their review of the surgeon’s credentialing file and takes action, as indicated.

The Under Secretary for Health reviews community care network contracts and considers modifying contracts to ensure that voluntary relinquishments and surrenders of licenses for disciplinary reasons are disqualifying for participation in VA’s Community Care Network consistent with the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures Optum’s sufficient review and discussion of community care network providers’adverse credentialing files and monitors for compliance.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum documents community care network provider credentialing decisions asrequired and monitors for compliance.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum complies with community care contract provisions to provide Integrated Veteran Care with accreditation and credentialing documentation in accordance with federal privacy laws and VA’s community care network contract.

The Office of Integrated Veteran Care Executive Director, Integrated External Networks verifies that providers identified on the 2021 Government Accountability Office list are eligible to provide care in the VA Community Care Network.

The VA Heartland Network Director initiates a review of all community care provided by the surgeon.

The VA Marion Health Care System Director ensures primary care and patient safety staff receive education on their responsibility for Joint Patient Safety Reporting and follow-up of patient safety events related to community care, and monitors compliance with patient safety event reporting and follow-up.

Direct the Office of Financial Management to continue to develop a system for digitally capturing, analyzing, and monitoring public questionnaires to identify inauthentic or potentially fraudulent questionnaires and work with the Compensation Service to develop policies for reviewing and remediating any such public questionnaires identified.

Have the Medical Disability Examination Office update the examiner certification and signature section found in public questionnaires to include that the form is being completed under the penalty of perjury and to ask examiners to list any organizations that requested they complete the examinations on the claimant’s behalf.

Instruct the Compensation Service to provide claims processors guidance in the procedures manual on how to identify a potentially fraudulent public questionnaire, and provide the steps they should take when they suspect that a public questionnaire may be inauthentic or potentially fraudulent.

Require the Compensation Service to inform claims processors as part of the public questionnaire review process that they have a duty to review and weigh all the evidence of record, including public questionnaires, and that they have the responsibility to assign low or no probative value if they have reason to suspect that the public questionnaire is inauthentic or potentially fraudulent.

Direct the Veterans Benefits Administration to develop and provide training on authentication and fraud, including training related to public questionnaires, to provide claims processors with the knowledge to identify inauthentic or potentially fraudulent public questionnaires, and include what steps claims processors should take when they make that determination.

The Executive Director ensures staff complete peer reviews for unanticipated deaths occurring within 24 hours of admission.

The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations for licensed independent practitioners.

The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Associate Director ensures managers maintain a safe and clean environment throughout the medical center.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen when it is clinically appropriate.

The Chief of Staff ensures providers complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.

The Chief of Staff ensures clinical staff notify the suicide prevention team if patients report suicidal or other self-directed violent behaviors that occurred in the 12 months preceding the Comprehensive Suicide Risk Evaluation.

The Chief of Staff ensures leaders appoint one full-time suicide prevention coordinator to each community-based outpatient clinic that serves at least 10,000 unique veterans annually.

The Chief of Staff ensures the Suicide Prevention Program Manager reports suicide-related events monthly to mental health leaders and quality management staff.

Develop specific policy and procedures to ensure the contractor’s investment grade audit, which includes the contractor’s energy baseline and cost savings estimates, are witnessed and validated per Federal Energy Management Program guidelines.

Publish criteria for payments for energy savings performance contracts to ensure compliance with federal law and Department of Energy Federal Energy Management Program guidance.

Develop procedures to ensure contracting officer’s representatives or other contracting officer designees have independently witnessed and validated the contractor’s energy baseline and savings estimates prior to negotiating energy savings performance contracts’ guaranteed savings amounts.

Develop oversight procedures to ensure documentation that demonstrates the contractor’s energy baseline and energy savings estimates were witnessed and validated is maintained in the official contracting records.

The executive director of VA’s Office of Construction and Facilities Management should confirm seismic evaluations are done for all critical and essential buildings in high and very high seismic zones immediately to ensure they meet life, safety, and occupancy performance standards

The executive director of the Office of Construction and Facilities Management should review the Capital Asset Inventory and work with Veterans Health Administration Office of Capital Asset Management, Veterans Integrated Service Network capital asset managers, and VA medical facility engineers to update and correct inaccurate seismic data in the Capital Asset Inventory.

The executive director of the Office of Construction and Facilities Management should submit change requests to the Capital Asset Inventory so that critical and essential designations are visible to medical center engineers and Veterans Integrated Service Network capital asset managers.

The executive director of the Office of Asset Enterprise Management should ensure facilities and Veterans Integrated Service Networks review critical and essential designations as part of their annual certifications of the Capital Asset Inventory.

Implement oversight, monitoring, and quality assurance mechanisms that routinely ensure all goods received by the Denver Logistics Center are accurately and promptly recorded in the inventory management system at the time of receipt.

Properly record all apnea stock in the inventory management system.

Ensure Denver Logistics Center management routinely assess the appropriateness of manual adjustments to the inventory system and document the findings and causes, review trends in error codes, and develop action plans to minimize inaccuracies in future physical counts.

Strengthen controls over inventory adjustments to ensure the accountable officer or designee reviews and approves supply variances above an established threshold.

Establish and implement policy that clearly defines roles and responsibilities for Denver Logistics Center logistics and warehouse employees, separates duties to avoid conflicts of interest, and enhances the quality assurance function.

Establish and implement formal policies and procedures specific for inventory management operations at the Denver Logistics Center, to include cycle counts, regular inventory audits, adjustments and forecasting demand, safety levels, reordering, and tools to allow for automated scanning.

Develop and deliver formal training to logistics and warehouse staff on inventory management policies, procedures, and tools.

Implement routine reporting of all Denver Logistics Center inventory adjustments to the National Acquisition Center and the Office of Acquisition, Logistics, and Construction.

Ensure the Denver Logistics Center staff complete reports of survey for adjustments to inventory in accordance with VA logistics management policy, and communicate such information to the National Acquisition Center.

Address the physical security issues identified and develop, implement, and provide initial and recurring training and guidance to Denver Logistics Center’s logistics, distribution, and contract staff on proper physical security controls and procedures, including the proper disposal of personally identifiable information.

Conduct an independent, comprehensive, and multiyear financial audit that includes wall-to-wall inventory assessments of the Denver Logistics Center.

Transfer the stewardship and responsibility for Denver Logistics Center systems to the Office of Information and Technology.

In collaboration with the Office of Information and Technology, establish information system controls for user access, segregation of duties designations, permission access, and privilege access for the inventory management systems and data.

Establish and perform routine reviews of the access levels for users with direct access to the inventory management systems and ensure that access is limited to those who have a defined business purpose.

In collaboration with the Office of Information and Technology, ensure the Denver Logistics Center meets physical access, security, and contingency planning requirements for its information management systems.

Establish a connection for Denver Logistics Center inventory data to VA’s Corporate Data Warehouse.

In collaboration with the Office of Information and Technology, ensure the information technology system application does not bypass internal control restrictions, has a complete audit trail, and does not introduce errors in the information system.

Ensure the Denver Logistics Center develops and maintains comprehensive documentation of the information system to support operations and train information resource management staff.

Ensure security documentation accurately supports the proper controls are implemented, tested, and representative of the system security.

Clarify guidance to ensure it includes local dialysis contract options and specifically defines when they should be used.

Establish roles and responsibilities to ensure dialysis coordinators follow required procedures when referring veterans to dialysis care in the community.

Develop and implement a plan to regularly examine and validate dialysis provider information in the Provider Profile Management System for accuracy and completeness.

Develop and implement a strategy to ensure that any new dialysis service contracts follow the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 payment rate requirements.

The Under Secretary for Health makes certain the Veterans Health Administration complies with requirements that all acute sexual assault victim-survivors are offered prophylaxis for sexually transmitted infection when clinically indicated and monitors compliance.

The Under Secretary for Health verifies compliance with Veterans Health Administration requirements that all acute sexual assault victim-survivors are offered prophylaxis for pregnancy when clinically indicated and monitors compliance.

The Under Secretary for Health ensures all sexual assault victim-survivors are offered mental health resources, either directly through Veterans Health Administration or through the community and monitors compliance.

The Under Secretary for Health ensures compliance with Veterans Health Administration requirements for documentation of signature informed consent for forensic examinations conducted by staff at Veterans Health Administration facilities and monitors compliance.

The Under Secretary for Health coordinates with VA Office of Security and Law Enforcement to provide direction that facility policy or guidance include facility and jurisdiction-specific information necessary for frontline staff to act in accordance with jurisdiction and Veterans Health Administration requirements for VA police responding to sexual assaults.

The Under Secretary for Health ensures Veterans Health Administration’s policy specifies the required elements to include in Veterans Health Administration facilities’ policies or guidance on acute sexual assault, including jurisdiction-specific requirements, and considers an online national policy with an appendix containing each facility’s supplemental information.

The Under Secretary for Health makes certain that facility level management of acute sexual assault policy or guidance is updated to incorporate information on facility-specific resources and jurisdictional requirements as warranted, and educates staff as needed.

The Under Secretary for Health ensures that VA Police Chiefs review facility policy and guidance for police responding to sexual assaults and update to incorporate information on facility-specific resources and processes, including jurisdictional requirements, as warranted, and educates facility police officers as needed.

The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Focused Professional Practice Evaluations for licensed independent practitioners.

The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day, when it is clinically appropriate, following a positive suicide risk screen.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff document veterans’ care coordination needs within the Community Care Coordination Plan note for consults assigned a level of care coordination above basic.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff act on consults no later than two business days after receipt and document accordingly.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff schedule community care appointments in a timely manner.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff make three attempts to retrieve medical documentation from non-VA providers.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures patients in the home dialysis program receive initial and annual home visits.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff implement and sustain processes to monitor the delivery of non-VA home dialysis.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures each Veterans Integrated Service Network establishes a dialysis council.

Coordinate with the executive director of the Prosthetic and Sensory Aids Service and officials from the Veterans Health Administration’s Procurement and Logistics Office and the VA Office of Acquisition, Logistics, and Construction to develop and implement a sourcing strategy, such as national contracts or a pricing catalog across all contracts by vendor for eyeglasses prescribed by a VA provider.

Coordinate with the executive directors of the Prosthetic and Sensory Aids Service and the Veterans Health Administration’s Office of Procurement to implement a process to ensure contracting officers coordinate before awarding any Veterans Integrated Service Network–level contracts for eyeglasses to make sure these vendors offer the Veterans Health Administration the best pricing that is also consistent for the same or similar items to the extent possible.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations for all licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ professional practice evaluations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider relevant Ongoing Professional Practice Evaluation data in reprivileging recommendations.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board uses professional practice evaluation results to recommend privileges for licensed independent practitioners.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures Automated External Defibrillator cabinets containing naloxone have alarms set in the “on” position, contain tamper-evident seals, display laminated “N” signs, and include naloxone inspection logs and administration reference cards.

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff check inventory in clean storerooms and remove expired supplies in the Emergency Department and medical/surgical inpatient unit.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Environmental Management Service maintains clean floors in the Dialysis Unit and medical/surgical inpatient unit clean storage and supply rooms.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain safe and functional environments in the Dialysis Unit and medical/surgical inpatient unit.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings safe and in good repair in the intensive care and medical/surgical inpatient units.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff repair damaged walls in the Dental Clinic and Emergency Department.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff replace stained ceiling tiles in the Emergency Department and Primary Care Red Team.

The Medical Center Director determines any additional reasons for noncompliance and ensures staff post signage where recording equipment is used in the intensive care and medical/surgical inpatient units, Dental Clinic, and Primary Care Red Team indicating the areas are subject to photography, digital imaging, video, or audio recording.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers assess whether patients’ most recent suicide attempt was their most lethal when completing the Comprehensive Suicide Risk Evaluation.