Date Issued
|
Report Number
21-00350-201
|
Topics: Financial Management
● Purchase Cards
All Reports
Date Issued
|
Report Number
20-03635-217
|
Topics: COVID-19
● Mental Health
● Patient Safety
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.
Date Issued
|
Report Number
21-00247-210
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/17/2021
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board reviews aggregated quality, safety, and value data.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/17/2021
The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board’s recommended improvement actions are fully implemented and monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Executive 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. 4
to Veterans Health Administration (VHA)
Closure Date: 1/19/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Date Issued
|
Report Number
20-00418-190
|
Topics: Financial Management
● Supplies and Equipment
Date Issued
|
Report Number
20-00418-166
|
Topics: Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel secure prescription drugs set aside for return credit either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel account for all prescription drugs set aside for return credit when they leave the medical facility either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel maintain inventory management practices to make sure drugs that are returned for credit are returned in a timely manner, so that medical facilities do not miss opportunities to maximize the value of their drug returns or reduce their risk of overspending to replace drugs prematurely returned for credit.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/1/2022
The OIG recommends that the under secretary for health takes steps to provide all offices and positions with defined national, network, or facility responsibilities for the drug return program or the administration of any future drug return contract(s), to include Pharmacy Benefits Management Services, Veterans Integrated Service Network pharmacist executives, network contracting officers, contracting officer representatives, and medical facility pharmacy chiefs, with the support, such as training, and the authority needed to carry out those responsibilities.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/21/2022
The OIG recommends that the under secretary for health makes sure that Pharmacy Benefits Management Services reviews the drug return contractor(s) data for accuracy, and uses this data to identify unusual reimbursement patterns and potential improvements for revenue recovery through the last invoices issued as part of the October 2018 Pharma Logistics contract, and for any future drug return contract(s); and coordinate with the National Contract Service on corrective action if inaccurate contractor data is identified.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health implements mechanisms to make sure that contracting officer representatives, if assigned, or Veterans Health Administration network contracting officers, provide oversight to ensure the contractor is performing in accordance with the terms of any future drug return contract(s).
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health, to minimize the risk of errors, makes sure that Veterans Health Administration network contracting officers when writing task orders off any future drug return contract(s) use a template with terms that align with any future drug return contract(s) developed by the National Contract Service.
No. 8
to Acquisitions, Logistics, and Construction (OALC),Veterans Health Administration (VHA)
Closure Date: 2/9/2022
The OIG recommends that the under secretary for health coordinate with the VA Office of Acquisition, Logistics, and Construction’s principal executive director, who should develop a task order template with terms that align with any future drug return contract(s) and require the National Contract Service to disseminate the template to Veterans Health Administration network contracting officers.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,907,365.00
Date Issued
|
Report Number
20-01796-195
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System develop a plan to work with the assigned prime vendor to address having adequate stock from the facility’s formulary list in its warehouse to provide supplies when ordered.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System ensure logistics staff use the tools available to inform the Medical Supplies Program Office of prime vendor performance issues.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The OIG recommended the director of the Miami VA Healthcare System establish controls to confirm approving officials and purchase cardholders review their proposed purchases and make sure contracting is used when it is in the best interest of the government.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System develop checks on the successful completion of quarterly audits of the purchase card program as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The OIG recommended the director of the Miami VA Healthcare System develop measures to confirm completed VA Form 0242 submissions are accurate and updated for all cardholders
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System provide guidance on implementing the healthcare system policy “Resource Management Board,” including measurable objectives or clear criteria to determine if a service line is efficiently managing administrative staffing.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System establish controls to make certain that budget or accounting staff review the salary cost data each pay period and promptly address cost center corrections with human resources staff as needed.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System ensure service chiefs and supervisors review labor mapping for accuracy and completeness.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System continue to develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The OIG recommended the director of the Miami VA Healthcare System establish measures to improve compliance with the VA directive to avoid end of year pharmaceutical purchases.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 328,000.00
Date Issued
|
Report Number
21-00255-200
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
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
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
Date Issued
|
Report Number
20-00041-163
|
Topics: Military Sexual Trauma
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/22/2022
Establish and implement a formal procedure to ensure all processing errors on claims identified by the review team are corrected and report the results to the OIG.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/30/2025
Develop, implement, and monitor a written plan to address continuing military sexual trauma claims processing deficiencies identified by the review team, including reassessing previously decided claims when appropriate, and report the results to the OIG.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2023
Strengthen controls to effectively implement and promote compliance with 2018 OIG report recommendations related to military sexual trauma claims.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2023
Develop, implement, and monitor a written plan that requires the Compensation Service and the Office of Field Operations to strengthen communication, oversight, and accountability of military sexual trauma claims processing.
Date Issued
|
Report Number
20-01979-199
|
Topics: Military Sexual Trauma
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/31/2022
The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding protected administrative time, administrative staff support, and funding for outreach, education, and special project resources, with consideration of the Military Sexual Trauma Coordinators’ responsibilities, and takes action as warranted.
Date Issued
|
Report Number
20-01262-191
|
Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Medical Center Director determines reasons for noncompliance and ensures that the Protected Peer Review Committee completes final reviews within 120 calendar days or has a written extension request approved by the Director.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/30/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses’ corresponding actions and outcome measures show sustained improvement.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in practitioners’ profiles.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff determines the reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic, with the veterans’ preference documented, within the required time frame.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete suicide safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five outreach activities each month.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual refresher training.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that written processes and procedures are in place for 24 hours per day, 7 days per week gynecological care.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned to and consistently attend Women Veterans Health Committee meetings.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Medical Center Director evaluates and determines the reasons for noncompliance and makes certain the Women Veterans Program Manager collects and tracks data for follow-up of abnormal mammogram and cervical cytology reports and the timeliness of breast and cervical cancer treatment.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/4/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment complete competency assessments.
Date Issued
|
Report Number
20-01254-185
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/4/2022
The Chief Medical Officer determines the 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
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead oversees facility development of corrective action plans within the required time frame and tracks action items until closure.
Date Issued
|
Report Number
20-02828-174
|
Topics: Patient Care Services Operations
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/18/2023
The OIG recommended the under secretary for health establish a process to ensure program personnel document veterans’ quarterly monitoring in their electronic health records, such as by using a standardized template.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The OIG recommended the under secretary for health etablish a process to ensure the provider agency list in the Electronic Claims Adjudication Management System is updated as new provider agencies are added to the program.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The OIG recommended the under secretary for health etablish a process to ensure proper pricing in the Electronic Claims Adjudication Management System when paying program claims.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The OIG recommended the under secretary for health update program guidance on claims submission and processing to make sure provider agencies are aware of the need to include all required information when submitting program claims.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/27/2023
The OIG recommended the under secretary for health establish guidance to include processes that medical facilities must follow to determine if veterans are receiving the same personal care services through the Veteran Directed Care program and the Program of Comprehensive Assistance for Family Caregivers, and how to address these situations, as appropriate.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/19/2022
The OIG recommended the under secretary for health ensure program personnel determine if veterans enrolled in both the Veteran Directed Care and the Program of Comprehensive Assistance for Family Caregivers are receiving the same personal care services and take action, as appropriate.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/26/2024
The OIG recommended the under secretary for health establish procedures to identify program staffing needs and define program personnel’s roles and responsibilities at the national, network, and local levels.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The OIG recommended the under secretary for health update procedures for tracking and reporting demand for and use of program services and use these data to inform yearly cost estimates for the program.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,570,395.00
Date Issued
|
Report Number
20-02368-202
|
Topics: Mental Health
● Care Coordination
● Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Ralph H. Johnson VA Medical Center Director ensures adherence to Veterans Health Administration policy in the renewal review of patients’ high risk for suicide patient record flag, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director evaluates compliance with Mental Health Treatment Coordinator assignment requirements, and takes action to address identified deficiencies as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director reviews the patient’s care to include staff’s adherence to “Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment” program requirements and appropriate outreach, consults with Human Resources and General Counsel Offices, and takes action as warranted.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Ralph H. Johnson VA Medical Center Director ensures that Mental Health Service staff complete patients’ suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director evaluates procedures for non-clinical staff to notify appropriate leaders of patient deaths by suicide, and takes action as needed.
Date Issued
|
Report Number
20-03763-207
|
Topics: Mental Health
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director ensures mental health staff consult with the Intimate Partner Violence Assistance Program and safety plan, as warranted to address Intimate Partner Violence.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Ralph H. Johnson VA Medical Center Director ensures Inpatient Mental Health Unit resident physicians complete timely clinical documentation in accordance with Ralph H. Johnson VA Medical Center Policy.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/3/2021
The Ralph H. Johnson VA Medical Center Director makes certain staff consult with the Office of General Counsel to determine reporting requirements of Intimate Partner Violence, as appropriate.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The Under Secretary for Health establishes clear guidance related to Intimate Partner Violence training requirements.
Date Issued
|
Report Number
20-01259-196
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/21/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager or designee includes all required review elements in root cause analyses.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs evaluate practitioners based on service-specific criteria.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines the reasons for noncompliance and makes certain the Executive Council of Medical Staff reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/16/2022
The System Director evaluates and determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/20/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Suicide Prevention Coordinator provides in-person Operation S.A.V.E. training at new employee orientation.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations within the required time frame.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures are reviewed at least every three years and updated when there is a change in process or manufacturer’s instructions for use.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director for Patient Care Services evaluates and determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures that all employees who reprocess reusable medical equipment receive monthly continuing education.
Date Issued
|
Report Number
21-00519-192
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 1/4/2022
The OIG recommended the under secretary for benefits ensure the Pension Program meets its reduction target.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The OIG recommended the under secretary for health ensure the Purchased Long-Term Services and Supports Program meets its reduction target.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/13/2023
The OIG recommended the under secretary for health reduce improper payments to below 10 percent for Beneficiary Travel; Communications, Utilities, and Other Rent; Medical Care Contracts and Agreements; Purchased Long Term Services and Supports; and VA Community Care Programs and activities.
Date Issued
|
Report Number
21-00657-197
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/7/2022
The VA Salt Lake City Healthcare System Director conducts a clinical review of the care provided to the patient on Monday (day 7), by Idaho Falls Community-Based Outpatient Clinic staff, and takes action as warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director reviews the processes involved in conducting root cause analyses to ensure that final reports contain complete and accurate information.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/16/2021
The VA Salt Lake City Healthcare System Director determines if an institutional disclosure is warranted following the completion of the clinical review of this patient’s care and takes action as necessary.
Date Issued
|
Report Number
20-01261-194
|
Topics: Patient Safety
● Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines the reasons for noncompliance and ensures that improvement actions recommended by the Executive Leadership Council are fully implemented and monitored.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/4/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee completes at least eight patient safety analysis processes each fiscal year.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee includes an analysis of underlying systems in all root cause analyses.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that improvement actions identified from root cause analyses are implemented.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The System Director evaluates and determines reasons for noncompliance and ensures the Patient Safety Manager or designee provides an annual patient safety report to healthcare system leaders.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document focused professional practice evaluation criteria in practitioner profiles.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that licensed independent practitioners’ professional practice evaluations are completed by providers with similar training and privileges.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that service chiefs’ reprivileging decisions are based on ongoing professional practice evaluation data.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Credentialing and Privileging Committee meeting minutes consistently reflect the review of professional practice evaluation results and the rationale for privileging recommendations.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 3/29/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing for patients prior to initiating long-term opioid therapy.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up evaluations of patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and effectiveness of the interventions.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 6/23/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete goals of care conversations and life-sustaining treatment decisions progress notes.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains the required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete competency assessments.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees receive monthly continuing education.
Date Issued
|
Report Number
19-08267-147
|
Topics: Clinical Care Services Operations
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Establish control mechanisms at the Veterans Integrated Service Network and Contracted Residential Services program levels to ensure Contracted Residential Services staff at medical facilities comply with Veterans Health Administration Handbook 1162.09 requirements for monitoring and documentation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
Direct Network Contracting Offices to establish controls to verify contracting officers meet with contracting officer’s representatives on at least a quarterly basis to evaluate contractor performance and document the meetings.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/14/2022
Direct Network Contracting Offices for all Contracted Residential Services contracts to ensure contracting officers include quality assurance surveillance plans and promptly issue letters of delegation to staff who have been nominated to be contracting officer’s representatives.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Update Veterans Health Administration Handbook 1162.09 to incorporate unannounced site visits to the extent possible during annual inspections and quarterly evaluations.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
Update Veterans Health Administration Handbook 1162.09 to include guidance on paying for veteran absences and make certain these requirements are reflected in contracts and surveillance plans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 35,300,000.00
Date Issued
|
Report Number
20-04341-182
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director confirms the Chief of Staff, the Service Chief, and the Supervisory Audiologist have processes in place to ensure patients affected by the audiologist’s poor care are identified and receive clinically-indicated follow-up.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s adverse event disclosure requirements, and takes action as indicated.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/27/2023
The Eastern Oklahoma VA Health Care System Director requires the Chief of Staff, the Service Chief, and the Supervisory Audiologist to complete clinical disclosures, as appropriate, for patients identified as being affected by the audiologist’s poor care.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates the process to determine whether a large scale disclosure is required, in accordance with the Veterans Health Administration policy.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s patient safety reporting requirements, and takes action as indicated.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The Eastern Oklahoma VA Health Care System Director directs the Chief of Staff, the Service Chief, and the Supervisory Audiologist to notify the Patient Safety Manager of adverse events identified through the review of patients impacted by the audiologist’s poor care.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures the Supervisory Audiologist verifies and documents annual competency assessments for audiologists in compliance with facility policy.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director ensures that the Supervisory Audiologist conducts performance appraisals of audiologists in compliance with the Veterans Health Administration policy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/17/2022
The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with Veterans Health Administration’s state licensing board reporting policy, and takes action as indicated.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/5/2022
The Eastern Oklahoma VA Health Care System Director initiates a review of the audiologist’s conduct to determine whether a report to the state licensing board is indicated, in accordance with the Veterans Health Administration policy.