All Reports

Financial Efficiency Review of the VA Black Hills Health Care System in South Dakota
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22-00066-184
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
The OIG made the following recommendation to the director of the VA Black Hills Health Care System: Ensure finance office staff conduct reviews on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2022
Establish procedures to ensure cardholders comply with processing requirements as stated in VA’s Financial Policy, vol. XVI, chap. 1B, “Government Purchase Card for Micro-Purchases.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2022
Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2022
Develop measures to confirm that completed VA Form 0242 submissions are accurate and updated for all cardholders.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
Ensure the supply chain management staff implement a plan to monitor and correct unit conversion factor errors consistently and promptly to improve data reliability in the Generic Inventory Package.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2023
Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration-recommended level.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2023
Establish measures to improve compliance with the VHA directive to avoid end-of-year pharmaceutical purchases.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 174,468.00
Deficiencies in Facility Leaders’ Oversight and Response to Allegations of a Provider’s Sexual Assaults and Performance of Acupuncture at the Beckley VA Medical Center in West Virginia
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21-03339-208
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Topics:  Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Capital Health Care Network Director reviews and evaluates the March 2021 Administrative Investigation Board action plan to identify open actions and ensures completion.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Beckley VA Medical Center Director ensures a review of Veterans Health Administration and Beckley VA Medical Center policies related to professional practice evaluations, including supervisory roles, review periods, and service-specific data collection, and takes action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Beckley VA Medical Center Director reviews and evaluates Veterans Health Administration and Beckley VA Medical Center policies related to disclosures and quality management actions such as look-back reviews and patient safety reporting to ensure such actions are timely, objective, and documentation is sufficient to address the issue under review.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022
The Beckley VA Medical Center Director ensures staff education of Veterans Health Administration and Beckley VA Medical Center policies related to employee misconduct and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
The Beckley VA Medical Center Director evaluates processes for reporting providers to the state licensing boards, including initial and comprehensive reviews, and monitors compliance.
Airborne Hazards and Open Burn Pit Registry Exam Process Needs Improvement
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21-02732-153
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Topics:  Appointment Scheduling and Wait Times
Related Media: Video

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2023

Ensure the program office and VA’s Office of Information and Technology work together to revise the questionnaire to make it clearer and easier for veterans to more quickly complete the questionnaire and schedule exams.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2023
Improve controls to ensure the registry website maintains accurate contact information for environmental health coordinators.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2023
Assess the feasibility of veteran-centric guidance that assigns medical facility follow-up responsibilities and identifies processes for determining whether unscheduled veterans with an interest in an exam still want to be scheduled, and then track responses and completions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2023
Implement a mechanism to ensure medical facilities meet the 90-day timeliness standard for the completion of requested exams, including performance metrics.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2023
Ensure Veterans Integrated Service Network and facility environmental health personnel routinely review their performance data and address any challenges with scheduling registry exams with directors.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2023
Ensure the program office reviews registry exam data and continues to work with VA’s Office of Information and Technology to ensure all facilities and veterans are included and properly coded.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2023
Establish procedures for medical facilities to transfer assigned veterans to receive an exam at a closer facility or as otherwise appropriate.
Veterans Prematurely Denied Compensation for Conditions That Could Be Associated with Burn Pit Exposure
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21-02704-135
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Topics:  Claims and Appeals
Related Media: Video

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/22/2022
Take any needed corrective actions on the four errors involving the improperly granted conditions based on burn pit exposure.
No. 2
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Review all denials of compensation claims identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions claimed by eligible veterans to be due to burn pit exposure; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.
No. 3
Open Recommendation Image, Square
to Veterans Benefits Administration (VBA)
Review all denials of compensation claims not identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions of bronchial asthma, chronic bronchitis, allergic rhinitis, sleep apnea, and chronic obstructive pulmonary disease submitted by veterans who served where and when burn pits were used even if not specifically cited in the claim; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/21/2023
Update the Adjudications Procedures Manual to provide separate and specific guidance for when claims should be considered based on burn pit exposure and proper development for these claims.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/21/2023
Modify the examination request web-based application to add specialty language into medical opinion requests for burn pit exposure claims, to include the contents from the fact sheet for burn pit claims.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/30/2023
Implement a plan to develop controls that review the accuracy of rating decisions going forward to minimize improper denials for burn pit claims, correct any errors identified, and address error trends.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/21/2023
Update training materials and ensure they are consistent with the adjudication procedures manual guidance for developing burn pit exposure claims.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 78,300.00
Inadequate Acceptance of Supplies and Services at Regional Procurement Office West Led to $12.8 Million in Questioned Costs
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21-01081-155
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Topics:  Financial Management ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
Establish controls to ensure contracting officers’ representatives upload required documentation of acceptability of supplies and services to the electronic contracting officer representative file prior to payment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
Establish a requirement and a process for branch chiefs to consistently monitor contract administration documentation.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2023
Assess existing contracts that require an electronic contracting officer representative file and take corrective actions to ensure compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2023
Establish controls to ensure contracting officers create an electronic contracting officer representative file for all contracts requiring a contracting officer’s representative.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2023
Assess existing contracts to ensure contracting officers have completed contracting officer’s representative delegation memorandums, if required.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Establish controls to ensure contracting officers and contracting officer’s representatives have a completed contracting officer’s representative delegation memorandum in the electronic contracting officer representative file, if required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
Establish a quality assurance process to ensure compliance with contract administration requirements for establishing an electronic contracting officer representative file, completing contracting officer’s representative delegation memorandums, and maintaining acceptance documentation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Assess whether additional training is needed to clarify officials’ roles and responsibilities for documenting acceptance of supplies and services.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 12,800,000.00
Review of Veterans Health Administration’s Response to a Medication Recall
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21-02194-198
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health evaluates current guidance regarding the monitoring and reporting of medication recall adverse drug events and makes changes as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2022
The Under Secretary for Health reviews vulnerabilities in the medication recall process due to variances in Veterans Health Administration medical facility processes and makes changes as necessary.
The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm
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22-01137-204
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Topics:  Electronic Health Records Modernization (EHRM) ● Patient Safety

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No. 1
Not Implemented Recommendation Image, X character'
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/28/2022

The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 2/13/2023

The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.

Senior Staff Gave Inaccurate Information to OIG Reviewers of Electronic Health Record Training
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21-02201-200
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/7/2022

Issue a clarifying communication to the office’s personnel that all staff have a right to speak directly and openly with Office of Inspector General staff without fear of retaliation, and that, irrespective of any processes established to facilitate the flow of information, Electronic Health Record Modernization Integration Office personnel are encouraged to communicate directly with OIG staff when needed to proactively clarify requests and avoid confusion.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 9/7/2022

Provide clear guidance that the office’s personnel must provide timely, complete, and accurate responses to requests for all data or information without alteration, unless other formats are requested, with full disclosure of the methodology, any data limitations, or other relevant context. This includes prompt OIG access to entire datasets consistent with the Inspector General Act of 1978, as amended.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023

Determine whether any administrative action should be taken with respect to the conduct or performance of the executive director of Change Management.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 8/15/2022

Determine whether any administrative action should be taken with respect to the conduct or performance of Change Management’s director for training strategy.

Comprehensive Healthcare Inspection of Veterans Integrated Service Network 5: VA Capitol Health Care Network in Linthicum, Maryland
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21-00239-180
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/17/2023
The Chief Medical Officer determines the reason for noncompliance, reviews the credentials file, and approves the VA appointment for physicians who had a potentially disqualifying licensure action.
Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia
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21-00287-194
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Topics:  Patient Safety ● Care Coordination ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders properly identify adverse events as sentinel events when criteria are met and conduct institutional disclosures, as required.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Health Systems Specialist participates on the VISN Systems Redesign Review Advisory Group.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend Facility Surgical Workgroup meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate all patient transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all Employee Threat Assessment Team members complete the required training.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2023

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

Contract Closeout Compliance Needs Improvement at Regional Procurement Offices Central and West
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21-02599-156
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Topics:  Contract Integrity

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2023
Establish procedures for consistent quality assurance reviews to ensure all contract closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, update Veterans Health Administration policies and procedures to provide guidance on conducting and documenting the reviews.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Assess and determine how to effectively distribute contracting officer workload and address imbalances among staff to help ensure contract closeouts are completed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Clarify the Veterans Health Administration procurement manual to indicate when simplified acquisition procedures closeout processes are to be used and the documentation requirements for each contract closeout step.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Determine whether setting aside specific time weekly to focus on contract administration tasks, such as contract closeout, and using contractors to perform closeout procedures could improve contract closeout compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2022
Ensure the contract files for the 81 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,400,000.00
Financial Efficiency Review of the VA Boston Healthcare System in Massachusetts
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21-03853-174
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations, and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Programs.”
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure supply chain management staff implement a plan to improve data reliability within the Generic Inventory Package system.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2023
Ensure the chief of supply chain management signs quarterly physical inventory memorandums of “A” classified items and makes them available to Veterans Integrated Service Network personnel as required in the VHA’s Directive 1761 Supply Chain Management Operations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2023
Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 379,439.00
Pharmacists’ Practices Delayed Buprenorphine Refills for Patients with Opioid Use Disorder at the New Mexico VA Health Care System in Albuquerque
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21-03195-189
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Topics:  Patient Safety ● Mental Health

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2023
The New Mexico VA Health Care System Director ensures that facility practice is consistent with Veterans Health Administration and facility policy applicable to early refills of buprenorphine for patients receiving opioid agonist therapy for opioid use disorder and is consistent with evidence-based treatment and prescribing providers’ clinical rationale, ensures all relevant staff are educated on the policy, and monitors for compliance with policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/16/2023
The New Mexico VA Health Care System Director ensures communication between provider, pharmacist, and patient for early medication refills and monitors for compliance with Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The New Mexico VA Health Care System Director clarifies the roles and responsibilities of the Opioid Safety Committee as related to buprenorphine treatment for patients with opioid use disorder, and ensures relevant staff are educated regarding the Opioid Safety Committee’s role in buprenorphine treatment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2022
The New Mexico VA Health Care System Director reviews buprenorphine prescribing provider concerns regarding the Opioid Agonist Therapy (Buprenorphine) for Opioid Use Disorder standard operating procedure and ensures the planned revision and implementation of the standard operating procedure is consistent with evidence-based treatment and includes language that specifies allowance for clinical judgment and a patient-centered care approach.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The New Mexico VA Health Care System Director reviews prescribing provider staffing levels in accordance with the Substance Use Disorder program’s needs and facility’s plans for expanding buprenorphine treatment in other clinical areas, and develops an action plan to address recommendations, if any, from the staffing level review.
VA Medical Facilities Took Steps to Safeguard Refrigerated Pharmaceuticals but Could Further Reduce the Risk of Loss
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21-01898-152
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Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2023
Direct the assistant under secretary for health operations to reinforce to medical facility directors the importance of establishing a process to ensure facility managers include pharmaceutical refrigerators and freezers in the facility’s routine maintenance schedules and develop and implement a procedure to make sure medical facilities follow VHA Notice 2021-16.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2022
Require the assistant under secretary for patient care services to coordinate with the assistant under secretary for health operations to update the 10N Guide to VHA Issue Briefs and clarify that medical facilities must report all refrigerated pharmaceutical loss via the issue brief tracker.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,100,000.00
Failure of Leaders to Address Safety, Staffing, and Environment of Care Concerns at the Tuscaloosa VA Medical Center in Alabama
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21-03201-185
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Topics:  Patient Safety ● Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The Tuscaloosa VA Medical Center Director provides oversight of the purchase and installation of an electronic alarm system for all Community Living Center neighborhoods and cottages and confirms ongoing monitoring of its use after installation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/23/2022
The Tuscaloosa VA Medical Center Director confirms completion of the risk analysis recommended in the facility-initiated risk assessment to determine if the Azalea House is suitable for the patient population residing there.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The Tuscaloosa VA Medical Center Director ensures that all security cameras are operable and labeled appropriately and develops and monitors a plan for ongoing testing and maintenance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director directs staff to assess the effectiveness of the outdoor fencing and gates surrounding Azalea House as a security measure to prevent Community Living Center residents at-risk for elopement from leaving the facility campus.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2023
The Tuscaloosa VA Medical Center Director establishes a review process to ensure that Community Living Center residents determined to be high risk for elopement have documentation consistent with Tuscaloosa VA Medical Center policy in their electronic health records identifying residents’ risk status.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director collaborates with the Veterans Integrated Service Network 7 Senior Strategic Business Partner to determine difficult to fill job series and develops a plan to maximize use of available tools for coverage, recruitment, and retention.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director ensures completion of a review of the facility’s Comprehensive Environment of Care program to confirm that patient care areas are properly classified, all areas are inspected at the required frequency, and compliance is monitored.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director coordinates with subject matter experts and develops a plan to ensure that the facility’s Comprehensive Environment of Care program effectively identifies areas in need of attention to provide a clean and safe environment for patients, visitors, and staff.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2023
The Tuscaloosa VA Medical Center Director confirms that Engineering Service staff conduct rounds of the grounds according to Tuscaloosa VA Medical Center policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2023
The VA Southeast Network 7 Director ensures completion of the Tuscaloosa VA Medical Center’s action plan to address recommendations made as a result of the October 2021 Veterans Integrated Service Network site visit.
Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia
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21-03349-186
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Topics:  Care Coordination ● Community Care ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2023
The Hampton VA Medical Center Director ensures that providers communicate, act on, and document a review of test results consistent with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2023

The Hampton VA Medical Center Director determines why the abnormal prostate-specific-antigen test results were not alerted to an ordering or surrogate provider and if other patient test results during that time frame also warrant review.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director reviews the urology consult template and, if appropriate, ensures the specific imaging required for consultation is specified in the template.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that procedures are in place to identify and reduce errors when staff place nuclear medicine orders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that facility staff submit patient safety reports consistent with Veterans Health Administration and Hampton VA Medical Center policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2023
The Hampton VA Medical Center Director ensures that quality management staff initiate timely quality reviews when deficiencies in patient care are identified.
Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2021
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22-00576-178
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2023
The acting under secretary for health take necessary measures to reduce improper and unknown payments to below 10 percent for Beneficiary Travel, Medical Care Contracts and Agreements, Purchased Long-Term Services and Supports, and VA Community Care programs and activities.
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