All Reports

Comprehensive Healthcare Inspection of the VA Portland Health Care System in Oregon
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20-01257-180
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Topics:  Patient Safety ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety and Value Council’s recommended improvement actions are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures the Utilization Management Committee’s recommended improvement actions are fully implemented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures all root cause analysis actions are fully implemented.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
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. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of aberrant drug-related behaviors prior to initiating long-term opioid therapy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing as recommended for patients on long-term opioid therapy.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/4/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct follow-up assessments that include adherence to the pain management plan of care and effectiveness of the interventions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete life-sustaining treatment decisions progress notes prior to hospice referrals.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Women Veterans Health Committee meetings.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures standard operating procedures are kept up-to-date and reviewed at least every three years.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Endoscopy Clinic clean storage room maintains the required relative humidity range.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2022
The Deputy Director for Patient Care Services determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho
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20-01256-179

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain a licensed healthcare professional’s first- or second-line supervisor completes provider exit review forms within seven business days of professionals’ departure from the medical center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five suicide prevention outreach activities per month.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all staff complete annual suicide prevention refresher training. 
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/2/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners complete life-sustaining treatment decision progress notes.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that processes and procedures are in place for 24 hours a day, 7 days per week Emergency Department and medical center call coverage for gynecologic care.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Medical Center 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 or arrangements for leave coverage when there is only one designated provider.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that align with medical center standard operating procedures prior to reprocessing reusable medical equipment.
Deficiencies in the Completion of Community Care Consults and Leaders’ Oversight at the New Mexico VA Health Care System in Albuquerque
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20-00716-177
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Topics:  Community Care ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director verifies monitoring is in place to ensure that clinical documentation is obtained from non-VA providers, scanned into the electronic health record, and attached to the applicable consult prior to completion of the consult.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2021
The New Mexico VA Health Care System Director evaluates program effectiveness and monitors the Chief of Community Care’s implementation of the competency and training program for Community Care Service nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2022
The New Mexico VA Health Care System Director confirms the Consult and Access Management Steering Committee updates its charter and oversees all aspects of the consult process as required by the Veterans Health Administration consult management policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director determines that staff responsible for monitoring and oversight, as identified by the Chief of Staff and the Consult and Access Management Steering Committee, develop and implement a process to evaluate Community Care consult processes and procedures for consistency with Veterans Health Administration policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The New Mexico VA Health Care System Director reviews the organizational structure of the facility’s Community Care Department, including available positions, evaluates the expertise of leaders and supervisory staff to ensure effective management and oversight, and takes action as necessary.
VBA Overpaid Veterans Due to Delays in Reducing Compensation Benefits
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20-03229-155

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Establish, document, and implement a workload management strategy to distribute and process proposals to reduce benefits that minimizes delays and excessive payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/18/2021
Develop, document, and implement a formal procedure to routinely monitor the workload management strategy to ensure it minimizes delays and excessive payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 348,000,000.00
Training Deficiencies with VA’s New Electronic Health Record System at the Mann-Grandstaff VA Medical Center in Spokane, Washington
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20-01930-183
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Topics:  Electronic Health Records Modernization (EHRM)

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2023
The Under Secretary for Health explores the establishment of a group of Veterans Health Administration staff comprised of core user roles with expertise in Veterans Health Administration operations and Cerner electronic health record use with data architect level knowledge to lead the effort of generating optimized Veterans Health Administration clinical and administrative workflows.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary establishes an electronic health record training domain that ensures close proximation to the production environment and is readily available to all end users during and following training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary ensures end users receive training time sufficient to impart the skills necessary to use the new electronic health record prior to implementation.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary ensures the user role assignment process addresses identified facility leaders and staff concerns.
No. 5
Not Implemented Recommendation Image, X character'
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary ensures Cerner trainers and adoption coaches have the capability to deliver end user training on Cerner and Veterans Health Administration electronic health record software workflows.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/1/2022
The Deputy Secretary evaluates the process of super user selection and takes action as indicated.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary reviews the Office of Electronic Health Records Modernization’s performance-based service assessments for Cerner’s execution of training to determine whether multiple, recurrent concerns are being accurately captured and addressed.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 9/20/2022
The Deputy Secretary oversees the revision of an Office of Electronic Health Records Modernization training evaluation plan and ensures implementation of stated objectives.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of the Secretary (SVA)
Closure Date: 2/1/2022
The Deputy Secretary reviews the Electronic Health Record Modernization governance structure and takes action as indicated to ensure the Under Secretary for Health’s role in directing and prioritizing Electronic Health Record Modernization efforts is commensurate with the Veteran Health Administration’s role in providing safe patient care.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/5/2022
The Under Secretary for Health establishes guidelines and training to capture new electronic health record-related patient complaints, including patient advocacy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The Under Secretary for Health ensures an assessment of employee morale following implementation of a new electronic health record and takes action as indicated.
Inadequate Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations
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20-03704-165
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
Establish procedures at all facilities with affiliated nonprofit corporations to help ensure VA medical center Research and Development Budget Office staff review nonprofit corporation invoice documentation and confirm services were performed before approving payment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2022
Establish procedures for Research and Development Budget Office supervisors at all the VA medical centers with affiliated nonprofit corporations that ensure periodic reviews are conducted of invoices authorized for payment, confirming that staff verified services were performed before approving payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2022
Ensure the Nonprofit Program Office invoice review procedures incorporate verification that affiliated nonprofit corporations include evidence that services were provided with invoices submitted to VA.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 17,900,000.00
Unreliable Information Technology Infrastructure Cost Estimates for the Electronic Health Record Modernization Program
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20-03185-151
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Topics:  Electronic Health Records Modernization (EHRM) ● System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Electronic Health Record Modernization Integration Office (EHRM IO)
Closure Date: 11/9/2022

Ensure an independent cost estimate is performed for program life-cycle cost estimates related to information technology infrastructure costs.

No. 2
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Reassess the cost estimate for Electronic Health Record Modernization program-related information technology infrastructure and refine as needed to comply with VA’s cost-estimating standards. 

No. 3
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Develop procedures for cost-estimating staff that align with VA cost-estimating guidance.

No. 4
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Ensure costs for all information technology infrastructure upgrades funded by the Office of Information and Technology and the Veterans Health Administration or other sources needed to support the Electronic

No. 5
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Formalize agreements with the Office of Information and Technology and the Veterans Health Administration identifying the expected contributions from each entity toward information technology infrastructure upgrades in support of the Electronic Health Record Modernization program.

No. 6
Open Recommendation Image, Square
to Electronic Health Record Modernization Integration Office (EHRM IO)

Establish procedures that identify when life-cycle cost estimates should be updated and ensure those updated estimates are disclosed in the program’s congressionally mandated reports.

Comprehensive Healthcare Inspection of Veterans Integrated Service Network 10: VA Healthcare System Serving Ohio, Indiana and Michigan in Cincinnati
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20-01265-172
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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: 7/1/2021
The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the credentials files of physicians who had a potentially disqualifying licensure action are reviewed with Regional Counsel, or a designee, and submitted for approval of VA appointment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/1/2021
The Network Director evaluates and determines any additional reasons for noncompliance and appoints a Veterans Integrated Service Network lead women veterans program manager.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead women veterans program manager provides quarterly program updates to executive leaders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2021
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead women veterans program manager completes annual site visits at each facility within the Veterans Integrated Service Network.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2021
The Network Director determines the reasons for noncompliance and makes certain that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2022
The Network Director determines the 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.
Failure of a Primary Care Provider to Complete Electronic Health Record Documentation and Inadequate Oversight at the Charlie Norwood VA Medical Center in Augusta, Georgia
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20-00354-178
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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: 12/14/2021
The Charlie Norwood VA Medical Center Director confirms that the Chief of the Health Information Management program monitors documentation to include patient care episodes without an associated progress note as part of the ongoing electronic health record review process, and takes action as warranted.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The Charlie Norwood VA Medical Center Director ensures a policy defines the required time frame for providers to respond to view alerts.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/14/2021
The Charlie Norwood VA Medical Center Director continues to monitor providers’ compliance with responding to view alerts, evaluates the effectiveness of the implemented strategies to reduce unnecessary view alerts, and assesses the need for retrospective reviews of patient care related to accumulated view alerts.
VHA Made Inaccurate Payments to Part-Time Physicians on Adjustable Work Schedules
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20-01646-139
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Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2025

Ensure payroll personnel complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2025

Establish oversight procedures to make certain that part-time physicians submit and validate their subsidiary time sheets and that supervisors promptly certify the time sheets.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2024

Train newly assigned payroll personnel on agreement reconciliation procedures and develop follow-up procedures to prevent missed reconciliations because of staff turnover.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

Implement procedures to confirm service chiefs conduct quarterly reviews of all adjustable work hour agreements that include identifying physicians with significant variances from the agreements or indicators that the cap on part-time hours is likely to be exceeded and taking corrective actions.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2024

Document oversight procedures for monitoring and validating compliance with the requirements of the part-time physician on adjustable work schedules program.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2025

Direct the program office, in coordination with the VA Office of General Counsel, to determine whether medical centers committed Antideficiency Act violations by not correcting underpayments and preventing physicians from working above the annual limit of 1,820 hours.

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2025

Establish oversight procedures for monitoring and validating their medical centers’ compliance with the requirements of the part-time physician on adjustable work schedules program.

No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/8/2022
Complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 2/8/2022
Document oversight procedures for monitoring and validating that all reconciliations and payment corrections are completed when agreements expire or are terminated.
Total Monetary Impact of All Recommendations
Open: $ 16,600,000.00
Closed: $ 0.00
Inadequate Oversight of Contractors’ Personal Identity Verification Cards Puts Veterans’ Sensitive Information and Facility Security at Risk
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20-00345-77
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Topics:  Contract Integrity

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers obtain and maintain evidence of contractor-provided lists of all personal identity verification cards issued to contractor employees.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers maintain evidence documenting personal identity verification cards were returned to the issuing or designated office when the cards were no longer required and prior to closing the contract.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to evaluate the role of contracting officer’s representatives in the personal identity verification card process for contractor employees and assess whether updates to their letter of delegation and standard operating procedures are necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish policies and procedures outlining specific supervisory responsibilities for contracting officer oversight in accordance with the Government Accountability Office Standards for Internal Controls in the Federal Government.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess the contract completion statement template to determine whether to include the contractor-related personal identity verification card requirements.

No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures within the Procurement Audit Office for periodic reviews of contract files to determine compliance with the personal identity verification card requirements established in the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, require the results of these reviews to be reported to senior management to help determine whether corrective actions are required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to determine whether existing or planned systems can have the functionality to allow management to effectively and routinely monitor contractor employee personal identity verification cards or whether a new system should be established.

No. 8
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess whether contracting officers should be required to include the contractor-provided list as an explicit requirement in all Veterans Health Administration contracts that require issuance of personal identity verification cards to contractor employees.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures to ensure contracting officers include Federal Acquisition Regulation clause 52.204-9, “Personal Identity Verification of Contractor Personnel,” in contracts when required.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2025

The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to consider directing contracting officers to delay final payment to contractors on future contracts until all personal identity verification cards have been returned.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic
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19-09808-171
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Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2022
The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/2/2022
The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
Veterans Cemetery Grants Program Did Not Always Award Grants to Cemeteries Correctly and Hold States to Standards
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20-00176-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs develop controls to ensure state grants are prioritized and awarded in accordance with the Code of Federal Regulations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs develop and implement written policies and procedures for grant prioritization.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/15/2022
The OIG recommended the under secretary for memorial affairs evaluate all current national headstone and niche cover contracts for appropriate penalties and clauses for timeliness and quality issues and enforce and amend those contracts as necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 5/11/2022
The OIG recommended the under secretary for memorial affairs direct the Improvement and Compliance Service to assign levels of importance to standards and measures used for compliance reviews and test the inscription accuracy of all gravesites sampled.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 2/7/2024

The OIG recommended the under secretary for memorial affairs require all state and tribal cemeteries to submit certified condition and operations performance assessments annually.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 5/11/2022
The OIG recommended the under secretary for memorial affairs ensure representatives from all state and tribal cemeteries are provided opportunities to participate in National Cemetery Administration standards training via remote training options and monitor all training to ensure adequate participation.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs continue to seek an increase in cemetery grant funding in excess of $45 million
No. 8
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs ensure that the Improvement and Compliance Service follows up with Hawaiian cemeteries after action plans are submitted to ensure deficiencies are corrected.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 11/4/2021
The OIG recommended the under secretary for memorial affairs implement controls to ensure cemeteries that receive provisionally compliant or noncompliant scores during reviews are followed up with on a fixed and regular basis until sufficient corrective action plans are submitted.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 3/4/2024

The OIG recommended the under secretary for memorial affairs use accountability measures in the Code of Federal Regulations when appropriate if grantees do not take adequate steps to correct significant long standing deficiencies.

No. 11
Closed and Implemented Recommendation Image, Checkmark
to National Cemetery Administration (NCA)
Closure Date: 8/16/2023
The OIG recommended the under secretary for memorial affairs work with the State of Hawaii Office of Veterans’ Services to conduct an extensive assessment of all eight Hawaii state veterans cemeteries, including organizational oversight and operations, staffing needs (including training), gravesite marker accuracy, and grounds conditions.
Comprehensive Healthcare Inspection of the John D. Dingell VA Medical Center in Detroit, Michigan
|
20-01273-162

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a first- or second-line supervisor completes a provider exit review form within seven business days of a licensed independent practitioner’s departure from the medical center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/23/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all employees complete suicide prevention refresher training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned to the Women Veterans Health Committee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/8/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
VHA Needs More Reliable Data to Better Monitor the Timeliness of Emergency Care
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20-01141-145
|
Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health ensure Baltimore VA Medical Center leaders reevaluate their corrective action plan and adjust as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health make certain relevant staff receive appropriate training on recording wait times in the software.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2022
The OIG recommended the under secretary for health strengthen reliability reviews of Emergency Department Integration Software data to mitigate the risk of inaccurate records.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2023
The OIG recommended the under secretary for health establish routine oversight responsibilities for Veterans Integrated Service Network and facility leaders of emergency departments’ efforts to improve the reliability of their emergency department data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The OIG recommended the under secretary for health improve the monitoring of data for patients with the highest Emergency Severity Index levels of one or two receiving emergency care services.
Improper Feeding of a Community Living Center Patient Who Died and Inadequate Review of the Patient’s Care, VA New York Harbor Healthcare System in Queens
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20-02968-170
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director reviews the process of evaluating the Community Living Center nursing staff’s competency for resident feeding and validates their ability to safely feed residents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director ensures that Community Living Center nursing staff are trained on documentation requirements related to feeding of residents and verifies compliance with requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director evaluates documentation of resident feeding, including identifying the staff member who feeds a resident, and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director verifies that a comprehensive review of the patient’s care and death is completed, and evaluates the usefulness of including the pictures and video of the chicken in the review, and takes action as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2022
The VA New York Harbor Healthcare System Director ensures the Cardiopulmonary Resuscitative Committee evaluates identified issues and makes recommendations for improvement, confirms actions are implemented, and assesses the effectiveness of actions.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2022
The VA New York Harbor Healthcare System Director verifies staff are aware of what constitutes an adverse event and the requirements to submit incident reports when witnessing or becoming aware of an adverse event.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/24/2021
The VA New York Harbor Healthcare System Director evaluates the circumstances surrounding the patient’s death to determine if an institutional disclosure is warranted
Inspection of Information Technology Security at the VA Outpatient Clinic in Austin, Texas
|
20-01485-114
|
Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The OIG recommended the area manager for the Central Texas Veterans Health Care System implement more effective automated inventory management tools.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The OIG recommended the area manager for the Central Texas Veterans Health Care System implement a more effective patch and vulnerability management program that can accurately identify vulnerabilities and enforce patch application.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/10/2021
The OIG recommended the area manager for the Central Texas Veterans Health Care System ensure compliance with the media protection standard operating procedure for all employees who work with media storage and ensure compliance with marking and sanitization provisions.
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