All Reports

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance using objective criteria accepted by the practitioner.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews and evaluates licensed independent practitioners’ privileging requests and documents its review in the meeting minutes.

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete Focused Professional Practice Evaluations and document results in practitioners’ profiles.

The executive director for the Veterans Health Administration Office of Integrity and Compliance implements planned revisions of policies and procedures for the Office of Integrity and Compliance to ensure it performs accurate List of Excluded Individuals and Entities monitoring, including for individuals with alternative or prior names or using social security numbers (if accessible), and provides timely notification of potential violations to appropriate staff.

The executive director for the Veterans Health Administration (VHA) Office of Integrity and Compliance performs a one-time audit of VA employment records using corrected matching practices to determine whether any individuals on the List of Excluded Individuals and Entities are receiving payments using VA healthcare program funds, and, if so, whether additional revisions to policies and procedures of the VHA Office of Integrity and Compliance, the VHA Office of Human Capital Management, or any other element of VA are required to address the causes, including any related screening and/or monitoring process failures.

Ensure DROCs identify which raters meet all the requirements to issue decisions on complex appeals, and to communicate to managers and staff which raters meet those requirements.

Provide guidance to DROC supervisors on how to maintain VBMS routing rules, and have OAR establish a procedure to periodically ensure WIT and workload designations at the DROCs are in alignment.

Ensure the St. Petersburg DROC monitors the effectiveness of its modified procedures that only designated DROs are assigned informal conferences for complex appeals, and ensure complex appeal designation will be accounted for in future informal conference routing applications.

The Veterans Integrated Service Network Director evaluates the role of the Patient Safety/ Risk Management Subcommittee to determine the degree to which the subcommittee will address facility level performance with Patient Safety Program activities and tracking of action plans when a deficiency is identified, and updates the subcommittee charter as warranted.

The Under Secretary for Health evaluates the process for programmatic oversight by VA’s National Center for Patient Safety over Veterans Integrated Service Networks’ and facilities’ patient safety programs.

Conduct an all-personnel audit of Beckley VA Medical Center staff to ensure background investigation requirements were met, to include considering an all-personnel data match of relevant suitability records against comparable datasets from the Personnel Investigations Processing System, and report results to the Workforce Management and Consulting office for verification.

Establish a project management plan to conduct compliance checks at other Veterans Integrated Service Network 5 facilities and share the plan with other networks.

Evaluate staffing levels for the personnel suitability program and allocate staff as needed to meet VA timelines.

The Secretary of Veterans Affairs delegates to a responsible official the monitoring of VA facilities’ security-related vacancies and reports monthly on hiring trends and whether recent recruitment and hiring authorities established since the fiscal year 2021 Police National Strategic Recruitment Plan are resulting in improvements.

The Secretary of Veterans Affairs authorizes sufficient staff for the Human Resources and Administration/Operations, Security and Preparedness’ Office of Security and Law Enforcement to inspect the VA police forces, per the OIG’s 2018 unimplemented recommendation.

The under secretary for health ensures medical facility directors use appropriate measures to assess VA police staffing needs, authorizes associated positions, and leverages available mechanisms to fill vacancies.

The under secretary for health verifies that medical facility directors commit sufficient resources to make certain that facility security measures are adequate, current, and operational.

The under secretary for health directs Veterans Integrated Service Network police chiefs, in coordination with medical facility directors, facility police chiefs, and facility emergency management leaders, to present a plan to remedy identified security weaknesses, including inoperative cameras, unsecured doors, and the lack of security presence at main entrances.

The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness establishes policy that standardizes the review and retention requirements for footage captured by facility security cameras.

The Medical Center Director determines any additional reasons for noncompliance and makes certain the Comprehensive Environment of Care Coordinator or designee schedules and ensures completion of environment of care inspections in patient care areas at the required frequency or maintains documentation to support pandemic-related postponement.

Ensure that healthcare system finance office staff and initiating services are made aware of policy requirements to conduct reviews on all inactive open obligations and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”

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.

Develop a control to ensure required supporting documentation is received from vendors that ship directly to veterans.

Ensure all supplies are entered into the Generic Inventory Package as required by Veterans Health Administration policy.

Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package per Veterans Health Administration policy.

Ensure supply chain management staff implement a plan for staff training to increase awareness of internal controls and data reliability within the Generic Inventory Package.

Ensure the chief of supply chain services signs quarterly physical inventory memorandums of “A” classified items and make them available to Veterans Integrated Service Network personnel as required in the Veterans Health Administration’s Directive 1761 Supply Chain Management Operations.

Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.

Develop and implement a plan to complete monthly B09 reconciliation consistently to ensure discrepancies are corrected in a timely manner.

The Overton Brooks VA Medical Center Director evaluates the processes for the communication of abnormal radiology imaging results and ensures patients receive timely notification, per Veterans Health Administration and facility requirements.

The Overton Brooks VA Medical Center Director ensures oversee all clinical decisions and documentation made by residents and the oversight is reflected within the documentation.

The Overton Brooks VA Medical Center Director reviews the processes for assigning a provider surrogate and monitors compliance.

The Under Secretary for Health ensures that Veterans Integrated Service Network leaders provide adequate oversight to ensure adherence to the mental health residential rehabilitation treatment program access to care policy as required.

The Under Secretary for Health ensures the Office of Mental Health and Suicide Prevention develops, implements, and monitors action plans to meet Intensive Community Mental Health Recovery visit frequency requirements, to include program resource needs and the ongoing role for virtual care.

The Under Secretary for Health requires the Office of Mental Health and Suicide Prevention to develop a process for Intensive Community Mental Health Recovery programs to ensure veterans receiving low-intensity services do not represent greater than 20 percent of caseloads and to distinguish between veterans receiving high- and low-intensity services for accurate and effective program oversight.

The Under Secretary for Health identifies barriers and ensures healthcare systems develop, implement, and maintain contingency plans specific to Intensive Community Mental Health Recovery programs regarding veteran access to medications during emergencies, including long-acting injectable antipsychotic medications.

The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.

The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.

The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.

The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.

The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.

The North Las Vegas Medical Center Director ensures a review is conducted of the primary care provider’s electronic health record documentation in order to determine if blood pressure entries other than 120/80 are false and takes action as necessary.

The North Las Vegas Medical Center Director ensures that any identified false blood pressures are amended in the electronic health record in accordance with Veterans Health Administration policy.

The VA Maryland Health Care System Director ensures that Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints.

The VA Maryland Health Care System Director evaluates and strengthens the process to ensure that problem lists reflect current and active diagnoses, and takes action as necessary.

The Veterans Integrated Service Network Director reviews the supervision provided to the psychiatry trainee regarding the patient’s treatment, documentation, and document control, to include electronic health records and video recordings, and determines if standards were met, and takes action as indicated.

The Greater Los Angeles Healthcare System Director reviews the facility leader and staff responses, including those of the supervisor and patient advocate, to ensure the patient’s concerns were adequately addressed, and takes action as indicated.

The Greater Los Angeles Healthcare System Director ensures records control schedules, including one for video recordings, are completed for the Mental Health Department as required by Veterans Health Administration policy.

The Greater Los Angeles Healthcare System Director reviews processes related to the utilization of video recordings, in consultation with appropriate staff, to ensure compliance with Veterans Health Administration requirements.