All Reports

The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.

The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation data.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs report Focused Professional Practice Evaluation results to the Medical Executive Board.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews Ongoing Professional Practice Evaluation results and documents its review when making reprivileging recommendations to the Director.

The Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections at the required frequency.

The Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.

The Director determines any additional reasons for noncompliance and ensures staff maintain a safe environment in the inpatient mental health unit.

The Associate Director for Patient/Nursing Services determines the reasons for noncompliance and ensures only authorized personnel have access to medication and supply rooms.

Clarify roles and responsibilities of the Office of Integrated Veteran Care and third-party administrators with respect to ensuring non-VA providers receive and certify they have reviewed Opioid Safety Initiative guidelines in accordance with the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 and collaborate with the contracting office to modify the contracts as appropriate.

Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of the VA Opioid Safety Initiative training module.

Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of required prescription drug monitoring program queries

The Under Secretary for Health collaborates with the region 2 third-party administrator to ensure that community care providers submit documentation of care to the Veterans Health Administration including treatments provided specific to opioid risk mitigation (urine drug screening, prescription drug monitoring program checks) and all prescriptions, to include urgently/emergently prescribed opioids and utine/maintenance opioid prescriptions.

The VA Eastern Kansas Health Care System Director ensures system providers document evidence of Opioid Safety Initiative risk-mitigation strategies for patients who are on long-term opioids, as required by Veterans Health Administration policy.

The Under Secretary for Health develops and implements action requiring community care network providers to document evidence of application of Opioid Safety Initiative risk mitigation strategies when treating a veteran to whom they have rescribed opioids, and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.

The Under Secretary for Health develops and implements action requiring community care network providers to conduct and document completion of state prescription drug monitoring program queries consistent with VHA policy, prior to prescribing controlled substances, regardless of whether the prescriptions are urgent, emergent, routine or maintenance prescriptions and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.

The Under Secretary for Health considers issuing formal guidance to all Veterans Health Administration pharmacy staff regarding best practices for conducting state prescription drug monitoring program queries upon receipt of controlled substance prescriptions from community care network providers.

The Under Secretary for Health develops and implements a process to oversee compliance of VHA’s medication reconciliation process for patients receiving care in the community who are prescribed opioids to include recording of the prescriptions in the non-VA medication section of the medication profile.

The Under Secretary for Health considers options and implements a process for including non VA medications prescribed by community care providers in the data populating the opioid safety tools.

The VA Eastern Kansas Health Care System Director ensures that medications known to system staff are entered into the patient’s medication profile in the electronic health record.

The VA Heartland Network Director ensures the Veterans Integrated Service Network Community Care Oversight Council conducts oversight of community care network providers’ opioid prescribing practices and reports results through the Opioid Prescribing Community Providers’ SharePoint site.

The VA Heartland Network Director confirms that the VA Eastern Kansas Health Care System has a local process outlining expectations, roles, and responsibilities for completing reviews of community care network provider’s opioid prescribing practices and that the process is shared with system staff, initiated, and monitored.

The VA Eastern Kansas Health Care System Director continues efforts to recruit and hire staff to fill vacant pain management positions.

The Under Secretary for Health consults with the Office for Integrated Veteran Care to determine the value of including a review of community care network provider documentation for evidence of prescription drug monitoring program queries as a required element in VA’s Guidance for Community Provider Opioid Prescribing Practices Review.

The VA Eastern Kansas Health Care System Director ensures system staff and leaders are educated on the processes to report patient safety concerns involving community care network providers.

Implement technology improvements and demonstrate progress to ensure the accuracy and completeness of information on the hypertension summary sheet.

Implement a process to communicate any change in policy, procedure, or the claims processing manual associated with all automated diagnostic codes between the Office of Automated Benefits Delivery, the Office of Policy and Oversight, the Office of Field Operations, and Compensation Service to ensure guidance is clear and consistent for all claims processors.

Implement an improved quality assurance process and monitor the results to ensure the accuracy of hypertension summary sheets and final decisions.

Create or amend metrics to compare the timeliness of claims processing using automation tools versus the traditional process.

Ensure that Veterans Health Administration fiscal staff are trained on VA financial policy requirements for the preparation and approval of journal vouchers (including expenditure transfers).

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings and equipment safe and in good repair.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure providers counsel patients who have the potential to become pregnant on the risks and benefits of teratogenic medications prior to prescribing them and document this counseling in the electronic health record.

Establish robust oversight of the personnel suitability program within responsible office(s) that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.

Reimplement the monitoring program specifically required by VA Handbook 0710 as part of VA’s oversight efforts, or an appropriate equivalent, to identify and prevent systemic weaknesses in the personnel suitability program.

Assess program resources and allocate staff as needed to prioritize oversight of the personnel suitability program within responsible office(s).

Establish a plan to implement the updated staffing metrics for the Veterans Health Administration’s suitability function and consider using available hiring flexibilities.

Incorporate formal data-testing procedures (and data-matching as appropriate) of HR Smart and the VA Centralized Adjudication Background Investigation System (or any replacement systems) into the monitoring program discussed in recommendation 2.

Develop and execute a plan to collect, maintain, and access sufficient and appropriate data through a single system to support the tracking of background investigations from initiation to adjudication.

Establish a plan to ensure that future systems support the functionality needed to effectively oversee and manage the background investigation process, including addressing limitations identified in the current systems and incorporating the fields necessary to track timeliness metrics.

The assistant secretary for information and technology and chief information officer improve vulnerability management processes to ensure system changes occur within organization timelines.

The assistant secretary for information and technology and chief information officer develop and approve an authorization to operate for the special-purpose system.

The assistant secretary for information and technology and chief information officer include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.

The VA medical center director install uninterruptible power supplies to eliminate single points of electrical failure supporting the facility.

The VA medical center director ensure that hot and cold aisles in computer rooms, and electric and data cables are installed in accordance with VA standards.

The VA medical center director validate that appropriate physical and environmental security measures are implemented and functioning as intended.

The VA medical center director implement media sanitization methods in accordance with VA policy requirements.

Issue guidance clarifying that allergens are exempt from the public law and include how the determination was reached.

Formalize and communicate the process for manufacturers to request exemptions.

Formalize the internal process for granting exemptions.

Establish a procedure for monitoring covered drugs identified in this report as not commercially sold.

Develop a procedure to monitor covered drugs identified in this report as newly launched to ensure they have an established ceiling price, and make certain they are made available on the Federal Supply Schedule at the end of the 75-day period.

Request that noncompliant manufacturers identified by the Office of Inspector General conduct a self-audit and submit their findings for remediation.

Engage with the Food and Drug Administration to ensure that when manufacturers request new national drug codes, they are made aware of the public law requirements.

Require contracting staff at the National Acquisition Center to conduct a covered drug check for all of a manufacturer’s drugs when any pharmaceutical Federal Supply Schedule proposal or product addition modification is submitted.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct comprehensive environment of care inspections at the required frequency

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.

The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation within the required time frame for patients with a positive suicide risk screen.

The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures peer reviewers consistently document at least one of the nine aspects of care for Level 3 peer reviews.

The Chief of Staff evaluates reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all final Level 3 peer reviews.

The Director determines the reasons for noncompliance and ensures police document their response times to panic alarm testing in the mental health inpatient unit.

The Chief of Staff or Associate Director, Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures cameras used for patient safety monitoring do not record.

The Chief of Staff and Associate Director, Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure staff minimize risks of patients’ self-harm in the mental health inpatient unit.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff attempt weekly follow-up until mental health care is established for patients determined as intermediate or high-acute or chronic risk of suicide on the Comprehensive Suicide Risk Evaluation who are discharged home from the Emergency Department.

Develop and implement procedures to ensure the Veteran Readiness and Employment Service has properly researched and clearly understands changes to the laws and regulations that govern Chapter 31–only schools and training programs.

Review the existing manual requirements for waivers and coordinate with appropriate officials to ensure amendments to 38 United States Code § 3104(b) have been properly implemented and included in the manual.

Train all appropriate Veteran Readiness and Employment Service regional office staff to ensure waivers are obtained for each veteran with the required documentation in accordance with the manual before approval to attend a Chapter 31–only school or training program.

Coordinate with appropriate officials to determine whether the existing manual guidance for compliance surveys meets the requirements of 38 United States Code § 3693 as it applies to Chapter 31–only schools and training programs, and if necessary, update the manual and train appropriate Veteran Readiness and Employment Service regional office staff accordingly.

Develop and implement monitoring processes—to include veteran waivers, compliance surveys, and completeness of electronic folders—to provide Veteran Readiness and Employment Service reasonable assurance that Chapter 31–only schools and training programs are used as intended by law and regulations.

The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of the patient and third-party contacts, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

The Veterans Crisis Line Director expedites the alignment of the Medora documentation template with the VA and Department of Defense Clinical Practice Guideline and Veterans Crisis Line guidelines for suicide risk assessment classification levels.

The Veterans Crisis Line Director ensures and strengthens the quality management oversight of staff who provide crisis management services, including overtime coverage.

The Veterans Crisis Line Director confirms the retention of crisis management text conversations and establishes supervisory oversight protocols.

The Veterans Crisis Line Director ensures issue briefs accurately reflect the action plan.

The Veterans Crisis Line Director identifies criteria for immediate internal reviews of customers’ deaths by suicide and accidental overdose to identify crisis management and administrative performance improvement actions.

The Veterans Crisis Line Director conducts a full review of the patient’s text contact, determines whether an institutional disclosure is warranted, and takes action as indicated.

The Veterans Crisis Line Director monitors compliance with the submission and oversight of notification of a customer’s death, including timely submission of a suicide prevention coordinator consult.

The Veterans Crisis Line Director conducts a review of the interactions between the Director, Quality and Training, and staff in preparation and during the Office of Inspector General healthcare inspection, educates staff on the importance of fully cooperating, responding in an open and transparent manner, and avoiding any appearance of coordination between employees, and take actions as warranted.

The Veterans Crisis Line Director clarifies and strengthens procedures for complaint submission, provides staff training, ensures consistency with the Veterans Health Administration directive, and monitors compliance.

The South Texas Veterans Health Care System Director ensures that processes are established for timely death notification entry in patients’ electronic health records.

The South Texas Veterans Health Care System Director ensures that staff adheres to the January 2022 standard operating procedures for administrative and clinical actions following a patient’s or employee’s death by suicide.

The Veterans Crisis Line Director strengthens processes to ensure discontinuation of caring letters in a timely manner following notification of a patient’s death.

The South Texas Veterans Health Care System Director makes certain that the Suicide Prevention Program ensures full implementation of the Behavioral Health Autopsy Program as required by the Veterans Health Administration.

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

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing Professional Practice Evaluations of licensed independent practitioners.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs’ reprivileging recommendations are based, in part, on Ongoing Professional Practice Evaluation activities.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee considers professional practice evaluation results in decisions to recommend privileges.

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures staff complete Comprehensive Suicide Risk Evaluations.

The under secretary for health to make sure all scheduling guidance and other materials correctly refer to the date that should be used to determine wait-time eligibility for community care.

The under secretary for health to make sure the Office of Integrated Veteran Care provides ongoing oversight to ensure all facilities are using nationally approved scheduling tools.

The under secretary for health to develop an oversight process to verify that schedulers are using the correct dates to calculate wait-time eligibility for community care.

The under secretary for health to develop a mechanism to notify schedulers when it is appropriate to consider wait-time eligibility for community care regardless of which scheduling system schedulers are using.