All Reports

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.

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.

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 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.

The under secretary for benefits update the instructions provided to examiners for completing Gulf War general medical examinations to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317 and clarify the instructions and related procedures to reflect that an examiner’s determination that a disability pattern is an undiagnosed illness or a medically unexplained illness requires a written explanation.

The under secretary for benefits implement a plan to update the Gulf War general medical examination disability benefits questionnaire to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317.

The under secretary for benefits implement a plan to incorporate into the Gulf War general medical disability benefits questionnaires the clinical requirements listed in 38 C.F.R.§ 3.317 for an undiagnosed illness and a medically unexplained illness.

The under secretary for benefits implement a plan to incorporate into the appropriate medical disability benefits questionnaires the diagnostic criteria for functional gastrointestinal disorders from 38 C.F.R.§ 3.317 and require examiners to provide an explanation of whether the disorder is functional or structural. This should include a requirement that any necessary testing has been completed before examiners diagnose specific functional gastrointestinal disorders.

The under secretary for benefits update VA’s Adjudication Procedures Manual to clearly state that all the requirements of 38 C.F.R.§ 3.317 must be met to award benefits. Clarify and reiterate instructions to claims processors that benefits should only be awarded after taking into consideration the overall evidence of record.

Require the Office of Regulations, Appeals, and Policy and the program office for Member Services’ Eligibility and Enrollment Division to ensure that priority group assignment decision notices are provided with enrollment handbooks given to veterans.

Conduct national refresher training on the Electronic Health Record Modernization National Process Memorandum and assess training effectiveness

Consider updating VA Manual 21-4 to reflect that quality assurance measures include addressing failures to consider all Veterans Health Administration records as directed in the Adjudication Procedures Manual that are subject to an enterprise-wide search in the Compensation and Pension Records Interchange system whether or not directed to those records by the claimant and ensure staff are advised of the changes.

The Fayetteville VA Coastal Health Care System Director ensures time frames for interpretation of echocardiograms are formalized and monitors for compliance.

The Fayetteville VA Coastal Health Care System Director reviews Facility Policy 11-40, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge dated January 2022 and SOP 11-10, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge Standard Operating Procedure and confirms that policy and procedures for an admission requiring continuous renal replacement therapy align with equipment and trained staff available at the facility.

The Fayetteville VA Coastal Health Care System Director ensures facility staff are educated on the community living center delineation of after-hour coverage and monitors compliance.

The Fayetteville VA Coastal Health Care System Director confirms hospitalists are educated on reporting patient safety issues and monitors patient safety reporting compliance.

The VA Mid-Atlantic Health Care Network Director reviews privileging processes and policies to ensure that facility leaders follow privileging processes and monitors compliance.

The Fayetteville VA Coastal Health Care System Director requires the chief of medicine to use focused professional practice evaluations and ongoing professional practice evaluations to evaluate provider performance per policy and monitors compliance.

The VA Milwaukee Healthcare System director to establish a plan to use VA’s cost accounting system information for the development of relevant, detailed cost information and to identify alternative ways to reduce costs and enhance efficiency as identified by VA financial policy.

The VA Milwaukee Healthcare System director to consider a plan to align VA Milwaukee Healthcare System financial management practices with federal financial accounting standard practices. This could include using cost information for performance measurement, budgeting and cost control, and making economic choices.

The VA Milwaukee Healthcare System director to ensure initiating services communicate status of delivered orders in a timely manner so healthcare system finance staff can comply with VA Financial Policy, vol. 2, chap. 5, “Obligations Policy,” by ensuring monthly that proper accruals have occurred.

The VA Milwaukee Healthcare System director to collaborate with the Veterans Integrated Service Network chief financial officer and network contracting office to establish a monthly prioritized listing of contract modifications and canceled orders for goods or services that have not been addressed by contracting officers to ensure modification actions are completed.

The Veterans Integrated Service Network 12 director to work with the network contracting office to amend the current contract or establish a new contract to include all needed laboratory tests.

The VA Milwaukee Healthcare System director to establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.

The VA Milwaukee Healthcare System director to require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.

The VA Milwaukee Healthcare System director to develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package per Veterans Health Administration policy.

The VA Milwaukee Healthcare System director to develop better access controls over the contingency space, to ensure less accessibility to reduce missing inventory.

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

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

The Chief of Staff evaluates and determines reasons for noncompliance and ensures section or service chiefs define time frames for Focused Professional Practice Evaluations.

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

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures Medical Executive Council meeting minutes consistently contain its recommendations for privileging requests

The Associate Director, Operations evaluates and determines any additional reasons for noncompliance and ensures staff inspect, test, and maintain all medical equipment.

The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain equipment and furnishings in good working order and keep areas used by patients clean, safe, and suitable for care.

The Director evaluates and determines reasons for noncompliance and ensures that only breathable shower curtains are present in mental health inpatient unit bathrooms.

The Chief of Staff or Associate Director, Patient Care Service/Nurse Executive determines the reasons for noncompliance and ensures video or audio monitoring equipment installed for patient safety purposes does not record and is only accessed and viewed by Veterans Affairs healthcare providers.

The Richard L Roudebush VA Medical Center Director ensures the Chief of Staff, chief of medicine, and chief of cardiology, in consultation with the National Cardiology Program Office, reevaluate the Cardiology Department and establish and implement a long-term service plan that includes cardiology services and cardiologist and specialty cardiologist staffing levels.

The Richard L Roudebush VA Medical Center Director provides the chief of cardiology with the dedicated resources needed to develop, implement, and sustain Cardiology Department changes.

The Veterans Integrated Service Network Director provides oversight of the Richard L Roudebush VA Medical Center Director’s development and implementation of a long-term Cardiology Department plan, monitors the department’s progress, and ensures changes are sustained.

The Veterans Integrated Service Network Director ensures the Richard L Roudebush VA Medical Center Director continues to strengthen and maintain the Cardiology Department’s relationship with the university affiliate, including residency and fellow cardiology programs and joint efforts to recruit cardiologists.

The OIG recommended the under secretary for benefits assess the loan comparison statement controls implemented in December 2021 and 2022 to ensure they operate as planned and confirm borrowers receive these statements as required.

The OIG recommended the under secretary for benefits seek a legal opinion from the VA’s Office of General Counsel on the allowability of fees initially charged as itemized fees to be retroactively accepted as part of the 1 percent flat charge if unsupported, and then review the potential overcharges identified in the audit sample to determine if action is needed to make the borrowers whole.

The OIG recommended the under secretary for benefits develop and update policies and procedures to ensure invoices or bills are obtained for all third-party charges and lenders report itemized closing costs at the lowest level of detail.

The OIG recommended the under secretary for benefits develop and update policies and procedures for the state deviation process and requirements, assess the extent of missing VA authorizations on the schedule of state deviations and obtain the necessary documentation, and obtain a legal opinion from the VA’s Office of General Counsel on the allowability of state deviation charges in excess of the state-published amounts, and then review the potential overcharges identified in the audit sample to determine if action is needed to make the borrowers whole.

The OIG recommended the under secretary for benefits revise policies and procedures to comply with federal regulations on the itemization of costs charged under the 1 percent flat charge to ensure closing costs are properly charged.

The OIG recommended the under secretary for benefits obtain a legal opinion from the VA’s Office of General Counsel on the allowability of mortgage brokerage fees charged under the 1 percent flat charge, and then review the potential overcharge identified in the audit sample to determine if action is needed to make the borrower whole.

The OIG recommended the under secretary for benefits provide lenders at least annual communication about the importance of providing justifications for any loans not reported within 60 days.

The OIG recommended the under secretary for benefits modify policies and procedures for full-file loan reviews to include detailed steps for loan specialists to conduct reviews, as well as the risk factors and methodology for loan selection.

The OIG recommended the under secretary for benefits update policies and procedures to ensure the borrower is reimbursed for any overcharges identified during regional loan center quality reviews.

The Pension and Fiduciary Service clarifies procedural requirements to fiduciary hub staff on how to verify whether VA-derived funds of deceased beneficiaries must be returned to VA, including whether the fiduciary identified any valid will or heir to whom the funds are otherwise due.

The Pension and Fiduciary Service identifies existing or implements new electronic controls that allow VBA staff to track Fiduciary Program tasks, timeliness, and workload related to the return of deceased beneficiaries’ VA-derived funds to VA that would otherwise escheat to a state if not disbursed to heirs.

The Pension and Fiduciary Service and the Office of Field Operations establish a methodology and monitor workload to ensure the prompt return of deceased beneficiaries’ VA-derived funds.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by allowing a facility to conduct lung cancer screening while developing all mandated elements.

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements.

The Under Secretary for Health considers mandating eligible patients be offered lung cancer screening consistent with other required cancer screening in the Veterans Health Administration.