All Reports

Ensure the Palo Alto major construction project (project number 640-424) is brought into the Acquisition Program Management Framework.

Ensure the activities and artifacts required during the verify phase of the Acquisition Program Management Framework are completed for the Palo Alto major construction project (project number 640-424)—including a business case with cost, schedule, and performance goals approved by the Secretary.

Ensure a decision event to verify the need of the acquisition is conducted for the Palo Alto major construction project (project number 640-424) and a determination is made to terminate or continue this project based on VA’s strategic needs and the VA Palo Alto Health Care System’s clinical needs.

Ensure VA’s FY 2025 Agency Capital Plan is revised to show the Palo Alto major construction project’s current total estimated cost and the progress the project has made toward meeting its critical objectives.

Ensure processes and guidance are in place for the director of the Office of Construction and Facilities Management to provide appropriate oversight and management over minor construction projects consistent with the authority and responsibilities described in 38 U.S.C. § 312A.

Revise the Veterans Health Administration directive on minor construction projects to incorporate 38 U.S.C. § 312A requirements and develop a review process for confirming compliance with the Office of Construction and Facilities Management’s guidance and any applicable industry standards.

Review the Audie L. Murphy emergency department exam and fast-track rooms for compliance with applicable design and equipment standards and provide any recommendations to the executive director of the South Texas Veterans Health Care System.

Review an assessment by the Office of Construction and Facilities Management of the Audie L. Murphy’s emergency department for compliance with design and equipment requirements to determine what changes, if any, are necessary and take appropriate corrective action.

The facility Director ensures staff review primary care panel sizes and capacity levels to ensure they are accurate.

Reassess and clarify physical inventory requirements for equipment in medical facilities to ensure they are consistent with and meet the intent of VA Directive 7002.

Ensure that facility directors require custodial officers to regularly review nonexpendable inventory to determine whether the equipment is required and take appropriate action.

Ensure medical facility directors review inventory list compliance data to identify noncompliant services and implement a process to resolve noncompliance.

Ensure the Veterans Health Administration’s Procurement and Logistics Office, in coordination with VA’s Office of Acquisition and Logistics, regularly monitors inventory compliance data to identify and communicate with noncompliant facilities to proactively address delinquent inventories.

Require medical facilities to use a standardized report of survey dashboard to centrally report all lost, stolen, or damaged items.

Require medical facility directors to review inventory compliance and establish a process to ensure noncompliant equipment—to include equipment identified in this audit—is reported as lost, stolen, or damaged within required time frames.

Reiterate through formal communication that facilities and regional Veterans Integrated Service Networks are required to fully implement and use the Strategic Equipment Planning Guide and Enterprise Equipment Request process for equipment planning and approval and develop a system to monitor compliance and verifying facilities are using the process as required.

Ensure relevant staff complete training on the Strategic Equipment Planning Guide and Enterprise Equipment Request process that explains user roles and responsibilities.

Ensure facilities define and assign Strategic Equipment Planning Guide and Enterprise Equipment Request user roles and responsibilities as applicable.

Reiterate through the formal communication advised in recommendation 1 that the Strategic Equipment Planning Guide and Enterprise Equipment Request process are required for all equipment planning and approval—and clearly define whether there are any exceptions.

Specify when and which equipment purchases require review and approval by additional subject matter experts.

Ensure a disability compensation examiner who has completed PACT Act training provides an independent assessment and medical opinion for the 29 VHA and five VBA nonpresumptive PACT Act opinions identified by the Office of Inspector General that were provided before completing PACT Act training, and readjudicate the claims as needed.

Establish and use agreements with other VA medical facilities to help identify and schedule direct care when services are unavailable at a veteran’s local VA facility.

At least annually, emphasize to schedulers the proper methods (including the use of codes) to document when veterans opt out of community care.

Require the medical facility director at the Jesse Brown VA Medical Center in Chicago to make sure veterans who request mental health services are assessed for community care and informed of all potential care options.

Require medical facility directors in Veterans Integrated Service Network 12 to review and process consults initiated in the first quarter of fiscal year 2024 that remain in a pending, active, or scheduled status.

The principal executive director of the Office of Acquisition, Logistics, and Construction considers whether any additional training or other measures are necessary with respect to reporting the wrongdoing of a supervisor and the acceptance of free meals and drinks by VA employees during the February 2023 site visit.

The principal executive director of the Office of Acquisition, Logistics, and Construction determines whether any additional guidance, training, or oversight is needed with respect to ensuring VA employees do not improperly solicit sponsorships for VA events that do not primarily benefit veterans.

VA’s designated agency ethics official determines whether any additional steps need to be taken in connection with Ms. Dawson’s 2023 public financial disclosure based on the findings of this report.

Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.

Facility leaders ensure each service has a service-level workflow for test result communication that is consistent with VHA requirements.

The Director ensures the Chief of Staff attends Peer Review Committee meetings.

The Overton Brooks VA Medical Center Director conducts a comprehensive review of the patient’s hospitalization and takes action as indicated, including quality management improvement processes such as a peer review.

The Overton Brooks VA Medical Center Director ensures medical staff recognize the importance of obtaining hospitalized patients’ non-VA medical records and assesses the current processes for obtaining non-VA medical records, identifies any barriers to completion, and takes action as warranted.

The Overton Brooks VA Medical Center Director assesses the application of the one-to-one observation policy and practices at the facility, and takes action as warranted.

The Overton Brooks VA Medical Center Director reviews interim behavioral patient record flag processes to ensure implementation of safety strategies for staff and patients, and takes action as warranted.

The Overton Brooks VA Medical Center Director evaluates whether documentation of patient and patient-related behavioral events are reflected accurately in the electronic health record to facilitate continuity of care and communication among medical staff and takes action as necessary.

Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.

Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.

Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.

The Under Secretary for Health ensures the establishment of Veterans Integrated Service Network-level multidisciplinary cancer committees.

The Under Secretary for Health ensures Veterans Integrated Service Network staff submit an inventory of available oncology services and facility points of contact to the National Oncology Program Office annually.

The Under Secretary for Health ensures complexity level 1 and 2 facilities pursue membership in the National Cancer Institute’s National Clinical Trial Network or the National Cancer Institute Community Oncology Research Program.

The Under Secretary for Health ensures the establishment of facility-level multidisciplinary cancer committees, or partnering with another facility or Veterans Integrated Service Network to provide the required committee functions.

The Under Secretary for Health reviews the operations of oncology-related program offices to ensure the required oversight of Veterans Integrated Service Network and facility oncology program implementation.

Evaluate whether VA should establish an enterprise-wide governance structure for Caseflow development, consistent with VA’s initial comprehensive plan to Congress.

Develop a well-defined roadmap for the future development and implementation of Caseflow.

Enforce contract requirements through improved oversight, ensuring violations are identified and remediated.

Evaluate which staff should have access to and should update the Consult Toolbox when records are requested or received and update the “Consult Business Rules and Uses of the Consult Package Standard Operating Procedure” to reflect necessary changes.

Include controls within the Consult Toolbox to prevent errors and improve data quality, including controls on administrative closure of low-risk consults and documenting the records-retrieval method.

Update consult closure policies and procedures to clarify requirements for administrative closure and determine whether metrics for the percentage of records received should be a requirement and included in policy.

Determine whether Veterans Health Administration facilities’ community care offices should continue to be required to use the administrative closure report for oversight of administratively closed consults, and if not, determine what reports should be required.

Evaluate the workload of community care staff to determine the most efficient way to structure and execute their duties.

Determine if there are mechanisms to identify standardization opportunities and increase efficiency for improving records return processes.

Ensure community care staff follow procedures to reduce duplicate records received.

Evaluate ways to increase use of provider electronic records portals to reduce reliance on electronic fax when retrieving medical records.

Consider increased implementation of technologies to improve records processing once received to reduce the manual renaming of electronic files and uploading of records into the electronic health record.

Ensure records from the Joint Longitudinal Viewer are uploaded into the electronic health record.

The Medical Center Director ensures staff store clean and soiled utility items separately, maintain cleanliness, and dispose of expired items.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action to address concerns substantiated in factfindings, and that all patient safety concerns identified in factfindings are reviewed and addressed.

The VA Southern Nevada Healthcare System Director evaluates the need for additional factfinders, and takes action as warranted.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs take action timely when aware of patient safety concerns.

The VA Southern Nevada Healthcare System Director reviews the information outlined in this report, determines the need to initiate the state licensing board reporting process, and takes action as warranted.

The VA Southern Nevada Healthcare System Director requires clinical service chiefs and credentialing and privileging managers to receive education on the completion of provider exit review forms and that, when supervisory staff contact credentialing and privileging staff for initiation of the state licensing board reporting process, a process is in place to ensure the message is clear and received.

The VA Southern Nevada Healthcare System Director ensures that clinical service chiefs and staff are educated on the need and process for submitting Joint Patient Safety Reporting reports upon awareness of patient safety events in accordance with facility policy.

The VA Southern Nevada Healthcare System Director educates the Chief of Staff on the need to complete management reviews when warranted, ensures that a review occurs of the dental hygienist’s care of Patient C, and ensures disclosure is provided if warranted.

The VA Southern Nevada Healthcare System Director makes certain that the Chief of Staff utilizes high reliability organization principles and establishes a process for the communication of pervasive concerns regarding a provider’s care.

The Director ensures staff correct deficiencies found during comprehensive environment of care rounds or develop an action plan to address them within 14 business days.

The Director ensures staff conduct fire drills once per shift, per quarter, in each patient area.

Executive leaders ensure staff inspect all medical equipment timely, and equipment has preventive maintenance labels.

Executive leaders ensure staff properly clean patient care areas in the Emergency Department.

Executive leaders ensure staff keep exit pathways free from obstructions.

The Director ensures staff develop service-level workflows for the communication of test results.

The Director ensures staff implement a facility-wide process to monitor providers’ communication of urgent, noncritical test results to patients, and report compliance to an appropriate oversight committee.

Executive leaders ensure staff implement actions from root cause analyses timely, monitor actions for effectiveness and sustained improvement, and report compliance to an appropriate oversight council.

The Director evaluates the patient safety program, including staffing, to ensure executive leaders receive meaningful patient safety information and improvement project data.