All Reports

Comprehensive Healthcare Inspection of the Hampton VA Medical Center in Virginia
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21-00278-23
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Topics:  Care Coordination ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that required members regularly attend Surgical Workgroup meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that appropriately privileged transferring providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to inter-facility patient transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2022
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 area.
Deficiencies in Disclosures and Quality Processes for Perforations Resulting from Urological Surgeries at West Palm Beach VA Medical Center in Florida
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21-01049-39
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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: 6/28/2022
The West Palm Beach VA Medical Center Director evaluates clinical disclosure practices and takes action as warranted to ensure compliance with Veterans Health Administration Directive 1004.08.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director ensures that Patient A’s and Patient B’s episodes of care are reviewed to determine if an institutional disclosure is needed per Veterans Health Administration Directive 1004.08 and takes action accordingly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director evaluates facility compliance with Veterans Health Administration Directive 1004.08 regarding institutional disclosure processes and takes corrective actions as needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director explores reasons Joint Patient Safety Reports were not entered for some adverse events experienced by Patient A and Patient B and takes action accordingly to ensure compliance with Veterans Health Administration Handbook 1050.01.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director confirms that the Surgical Workgroup’s meeting minutes document oversight of the Surgical Service Morbidity and Mortality Conference by including issues discussed, conclusions, actions, recommendations, evaluations, and follow up in accordance with Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director identifies reasons a planned peer review was not completed in accordance with Veterans Health Administration Directive 1190 and takes corrective action as indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/2/2022
The West Palm Beach VA Medical Center Director reviews processes for evaluation of urologists’ privileging forms and takes action as necessary to ensure compliance with Veterans Health Administration Handbook 1100.19 and Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
Comprehensive Healthcare Inspection of the Fayetteville VA Coastal Health Care System in North Carolina
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21-00277-41
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Topics:  Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Workgroup meets monthly and core members consistently attend meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The OIG recommends that the principal executive director, Office of Acquisition, Logistics, and Construction direct the Strategic Acquisition Center’s Medical/Surgical Prime Vendor Program contracting officer to provide guidance to Veterans Integrated Service Network and VA medical facilities’ program contracting officer’s representatives on the emergency and continuous supply provisions in the contracts, and ensure contracting officers’ representatives inform network and facility managers of the strategies offered by the prime vendors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2024

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to the receiving facilities during inter-facility transfers.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The Chief of Staff and Associate Director of Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/7/2025

The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.1

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/3/2022
The Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete required training.
VHA Risks Overpaying Community Care Providers for Evaluation and Management Services
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21-01807-251
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Topics:  Community Care ● Financial Management

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the Health Information Management program office, in coordination with the Office of Community Care and facility chiefs of staff, to ensure facilities are conducting post payment audits of billed evaluation and management services to verify non VA providers are properly supporting their claims, including a focus on providers who frequently bill high level evaluation and management services and/or submit charges during periods when global surgery packages are in effect, and develop processes for corrective actions based on audit results.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2022
Ensure the Office of Community Care and the Health Information Management program office make any current and future continuing education material related to documenting evaluation and management services available to non VA providers.
Total Monetary Impact of All Recommendations
Open: $ 59,600,000.00
Closed: $ 0.00
VHA Improperly Paid and Reauthorized Non-VA Acupuncture and Chiropractic Services
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20-01099-249
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Topics:  Community Care ● Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2023
Ensure the Office of Community Care implements automated payment system controls to reject non VA claims that exceed the number of authorized visits or cutoff dates or includes treatment codes that deviate from established standards for care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/3/2022
Ensure the Office of Community Care conducts ongoing payment system audits to identify and minimize improper payments of unauthorized claims.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Direct the Health Information Management program office in coordination with the Office of Community Care and facility chiefs of staff to ensure facilities are conducting post payment audits of billed acupuncture and chiropractic services to verify non VA providers are properly supporting their claims and to develop processes for corrective actions based on audit results.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2022
Ensure the Office of Community Care and the Health Information Management program office, in coordination with the offices of Acupuncture and Chiropractic services, make any current and future continuing education material related to documenting acupuncture and chiropractic services available to non VA providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2023
Direct facility chiefs of staff to require those authorized to approve non VA care to document review of prior care before approving additional services.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2023
Instruct facility chiefs of staff to require VA providers to document their clinical justification for additional care requested by a veteran.
Total Monetary Impact of All Recommendations
Open: $ 341,700,000.00
Closed: $ 0.00
Comprehensive Healthcare Inspection Summary Report: Evaluation of Women's Health Care in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01508-32

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has processes and procedures in place for emergency care 24 hours per day, 7 days per week and facility call coverage for gynecologic care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/27/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a women veterans program manager who is full-time and free of collateral duties.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that each facility has a designated maternity care coordinator.
Systems and Tools Implemented to Track COVID-19 Vaccine Data
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21-00913-267
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/12/2022
The OIG recommended the under secretary for health develop processes for verifying facility data entered on the Pharmacy Benefits Management Services’ SharePoint website (or any subsequent data collection tool) for vaccine supply and usage.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health develop a process to monitor the use of tools that have been fielded to standardize data entry for vaccine doses administered by VA medical facilities and clinics to minimize data entry errors, including the Computerized Patient Record System’s clinical reminder, the Occupational Health Record-keeping System 2.0’s guided data entry guidance, and reports that can be used to identify data entry errors in these systems, or in any subsequent systems that VA uses to collect data on vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health make sure that the Power BI dashboard data are reliable, accurate, and complete, and capture all vaccine data more accurately for VA medical facilities in the same healthcare system.
VA Applications Lacked Federal Authorizations, and Interfaces Did Not Meet Security Requirements
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20-00426-02
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/17/2024

Review the SaaS applications named in the allegation to determine whether VA staff are still using them and whether such use is consistent with VA policy. If use is authorized, implement controls to ensure the applications go through the Federal Risk and Authorization Management Program authorization process and the VA SaaS application approval process. If use is not authorized, implement controls to prevent employees from using the SaaS applications without authority to operate.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/13/2022
Determine whether Federal Risk and Authorization Management Program authorization will be pursued for the IRBManager application. If the required federal authorization is not pursued, include this application in the annual certification letter to the Federal Chief Information Officer along with the appropriate rationale and proposed mitigation plan.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/13/2022
Implement JavaScript Object Notation Web Encryption for Lighthouse application programming interfaces that transmit sensitive information and resource-sharing requirements for cross-origin resource sharing to meet the requirements of VA Office of Information Security’s Application Programming Interface Security Pattern. Alternatively, coordinate with the Office of Information Security to determine if modifications or exceptions to security standards are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/13/2022
Implement alerts for application programming interface-related abuse to meet the requirements of the VA Office of Information Security’s Application Programming Interface Security Pattern.
Vet Center Inspection of Continental District 4 Zone 1 and Selected Vet Centers
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20-04050-37
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Topics:  Suicide Prevention
Related Media: Video

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director determines the reasons clinical and administrative quality review remediation plans do not include the Deputy District Director’s approval and date of approval as required and ensures compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director evaluates the clinical and administrative quality review process for resolution of quality review deficiencies and initiates action steps as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director evaluates the clinical and administrative quality review report process for determining timeliness in resolving quality review site visit deficiencies and initiates action steps as necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director determines the reasons critical incident quality reviews (currently known as mortality and morbidity review) for serious suicide attempts including analysis for corrective action were not completed, ensures completion, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director ensures the intake assessment portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director in collaboration with Readjustment Counseling Service Central Office evaluates the limitations of current tools and tracking methods including reasons completion dates are not visible in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director ensures clinical staff consult and coordinate care with the support Veterans Affairs medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with shared support Veterans Affairs medical facility for shared clients who are flagged as high risk for suicide and monitors compliance across all zone vet centers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/20/2022
The District Director ensures clinical staff consult with the vet center director, external clinical consultant or suicide prevention coordinator following a lethality status change as required and monitors compliance across all zone vet centers.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director in collaboration with the support Veterans Affairs medical facility clinical or administrative liaison determines the reasons for noncompliance with staff participation on mental health councils at the Casper, Denver, and Midland Vet Centers, and takes actions to ensure compliance with Readjustment Counseling Service requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director determines reasons an external clinical consultant was not assigned as required at the Midland Vet Center and ensures compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director determines reasons for noncompliance with processes for completing and tracking four hours per month of external clinical consultation at the Casper, Denver, El Paso, and Midland Vet Centers, and ensures that Vet Center Directors implement processes and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director determines reasons for noncompliance with staff supervision provided by the vet center directors at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that staff supervision occurs as required, and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director determines reasons for noncompliance with monthly RCSnet chart audits at the Casper, Denver, El Paso, and Midland Vet Centers, ensures that chart audits are completed as required, and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2022
The District Director determines reasons for errors in training assignments for staff at the Casper, Denver, El Paso, and Midland Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director evaluates and determines reasons tactile (braille) signage was not posted at all exit doors at the Casper, Denver, El Paso, and Midland Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The District Director reviews the reasons an updated emergency and crisis plan was not available at the Denver and Midland Vet Centers and ensures an updated plan is accessible to all staff.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The District Director reviews reasons for noncompliance with client record storage at the Denver, El Paso, and Midland Vet Centers and ensures all client records are stored as required.
Discharge Planning Deficits for a Veteran at the Malcom Randall VA Medical Center in Gainesville, Florida
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21-01695-38
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director reviews roles and responsibilities for interdisciplinary treatment team members and the process for communication of plans and recommendations from all clinical team members and takes action as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director ensures clinical staff follow established policy to alert clinical team of pertinent care changes by using the additional signer functionality or other methods of communication.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned occupational therapy provider involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the attending physician involved in the discharge planning for the patient and takes follow-up action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned social worker involved in the discharge planning for the patient and takes follow-up action as indicated.
Delayed Cancer Diagnosis of a Veteran Who Died at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico
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20-03700-35
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2022
The Raymond G. Murphy VA Medical Center Director ensures supervising providers oversee all clinical decisions made by residents and the oversight is reflected within the documentation, including telephone notes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2024

The Raymond G. Murphy VA Medical Center Director ensures supervising providers establish a reliable way to receive alerts for the results of all tests ordered by residents.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that Primary Care and Specialty Care staff coordinate care for shared patients and evaluates the need for Outpatient Care Coordination Agreements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director ensures that patient, family, or staff concerns regarding delay in diagnosis are entered into the patient safety reporting system and appropriate follow-up is completed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Raymond G. Murphy VA Medical Center Director coordinates a comprehensive review of the patient’s care, takes action as warranted, and reconsiders an Institutional Disclosure.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2023
The Raymond G. Murphy VA Medical Center Director ensures consistency between the relevant prior radiological images reviewed when staff radiologists and contract teleradiologists interpret imaging scans for Raymond G. Murphy VA Medical Center patients.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System in Bedford, Massachusetts
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21-00235-13
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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: 3/28/2023
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain to designate a mental health professional to serve on each state’s suicide prevention council or workgroup.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2022
The Network Director determines the reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to required Veterans Integrated Service Network leaders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager conducts assessments to identify staff’s women’s health education gaps and develops or adapts educational programs, materials, or resources where gaps are identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager has Veterans Integrated Service Network-level support staff for data analysis and performance improvement projects.
New Patient Scheduling System Needs Improvement as VA Expands Its Implementation
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21-00434-233
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Topics:  Appointment Scheduling and Wait Times ● 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),Veterans Health Administration (VHA)
Closure Date: 12/21/2022

Continue to make improvements to the scheduling training as needed to address feedback from schedulers.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 6/22/2023

Require that some schedulers from each clinic fully test the scheduling capabilities of their clinics, solicit feedback from the schedulers to identify system or process issues, and make improvements as needed

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024

Issue guidance to facility staff on which date fields in the new system schedulers should use to measure patient wait times.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 10/27/2022

Develop a mechanism to track and then monitor all tickets related to the new scheduling system, and then ensure the Office of Electronic Health Record Modernization evaluates whether Cerner effectively resolved the tickets within the timeliness metrics established in the contract.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 10/27/2022

Develop a strategy to identify and resolve additional scheduling issues in a timely manner as the Office of Electronic Health Record Modernization deploys the new electronic health record at future facilities.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO),Veterans Health Administration (VHA)
Closure Date: 7/14/2023

Develop a mechanism to assess whether facility employees accurately scheduled patient appointments in the new scheduling system, and then ensure facility leaders conduct routine scheduling audits.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2024

Evaluate whether patients received care within the time frames directed by Veterans Health Administration policy when scheduled through the new system.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 10/27/2022

Provide guidance to schedulers to consistently address system limitations until problems are resolved.

DMLSS Supply Chain Management System Deployed with Operational Gaps That Risk National Delays
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20-01324-215
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Topics:  System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Ensure the VA Logistics Redesign office revisits its Defense Medical Logistics Standard Support system oversight and deployment processes to align them with VA’s acquisition program management framework requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Develop processes to better identify unmet high-priority business requirements and post-deployment challenges at the Captain James A. Lovell Health Care Center and future sites and to make certain that solutions are developed and implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2023
Director of the Office of Acquisitions, Logistics, and Construction: Properly staff the VA Logistics Redesign office with personnel who possess the appropriate subject matter expertise and employ measures to improve continuity in the project management team that oversees the Defense Medical Logistics Standard Support system’s implementation.
Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic
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20-03437-26
|
Topics:  COVID-19 ● Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/12/2023

The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/12/2022
The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.
Inadequate Care Coordination for a Mental Health Residential Rehabilitation Treatment Program Resident in VISN 20, Oregon
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21-01682-25
|
Topics:  Mental Health ● Care Coordination ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2023
The Southern Oregon Rehabilitation Center and Clinics Director conducts an assessment to ensure all applicable elements of the Southern Oregon Rehabilitation Center and Clinics continuing care plan template are addressed when discharging residents from the Mental Health Residential Rehabilitation Treatment Program and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2023
The Southern Oregon Rehabilitation Center and Clinics Director ensures discharges of residents from the Mental Health Residential Rehabilitation Treatment Program occur during regular business hours in accordance with Veterans Health Administration Directive 1162.02.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director reviews Southern Oregon Rehabilitation Center and Clinics transportation policies to ensure alignment with Veterans Health Administration transportation directives, including management of the transport of residents with behavioral flags.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The Southern Oregon Rehabilitation Center and Clinics Director develops a process to ensure an updated medical evaluation is conducted should the admission team be notified of a change in medical status that occurs after a veteran’s initial admission screening medical evaluation but prior to admission to the Mental Health Residential Treatment Program.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Southern Oregon Rehabilitation Center and Clinics Director completes a systematic review of residents’ falls in the shower area on the Mental Health Rehabilitation Residential Program units and takes action as warranted.
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