All Reports

Stronger Financial Management Practices Are Needed at VA's Maryland Health Care System
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19-07719-113
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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: 8/6/2024

The OIG recommended the Maryland Health Care System director implement internal controls for healthcare system staff to submit and document approvals for all equipment requests in the Enterprise Equipment Request Portal before ordering and paying for equipment.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/14/2022
The OIG recommended the Maryland Health Care System director implement a control requiring staff to justify the waiver of any healthcare system approvals ordinarily required to purchase equipment in the Enterprise Equipment Request Portal.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/11/2022
The OIG recommended the Maryland Health Care System director inform the deputy under secretary for health for operations and management for procurement and logistics of the internal control weakness in the Enterprise Equipment Request Portal and request a response regarding whether corrective action is necessary.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director require the logistics service to develop a plan for working with the prime vendor to ensure historical and current estimated supply data are timely, accurate, and meet healthcare system supply requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The OIG recommended the Maryland Health Care System director ensure the logistics service implements a plan to monitor for and correct unit conversion factor errors consistently and promptly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2024

The OIG recommended the Maryland Health Care System director establish processes and controls for cardholders to comply with the record retention requirements in the Federal Acquisition Regulation and VA’s Financial Policy, Volume XVI, “Charge Card Program.”

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The OIG recommended the Maryland Health Care System director ensure all staff are provided clear guidance on overtime approval and payment policies and procedures that meet VA requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/8/2023
The OIG recommended the Maryland Health Care System director implement policies and procedures for supervisors to effectively monitor overtime worked and maintain documentation required to support related payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,552,000.00
Comprehensive Healthcare Inspection of the VA Northern Indiana Health Care System in Marion
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20-01270-154
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Topics:  Medical Staff Privileging Credentialing ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs base reprivileging decisions on service-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs ensure that ongoing professional practice evaluations for radiation oncologists include the minimum radiation oncology-specific criteria.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
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.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ determinations to continue privileges are based, in part, on results of ongoing professional practice evaluation activities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2022
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Clinical Executive Board’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2022
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 independent practitioners’ departure from the healthcare system.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures state licensing board reporting is initiated when a provider fails to meet generally accepted standards of practice.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
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 substance abuse, mental health problems or disorders, and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional 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. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans are completed within the required time frame.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete annual suicide prevention refresher training.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that gynecological care coverage is available 24 hours a day, 7 days per week.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief performs an annual risk analysis and reports the results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures the Sterile Processing Services supervisor enforces the daily cleaning schedule at the Fort Wayne campus.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Associate Director for 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. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees who reprocess reusable medical equipment complete competency assessments.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services employees receive monthly continuing education.
Entitled Veterans Generally Received Clothing Allowance but Stronger Controls Could Decrease Costs
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20-01487-142

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2024

The OIG recommended the under secretary for health revise the Veterans Health Administration handbook to include detailed roles, responsibilities, and procedures for determining entitlement to and monitoring of the clothing allowance benefit.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health develop and initiate a plan to reevaluate veterans’ entitlement to recurring clothing allowance benefits in collaboration with the Veterans Benefit Administration.
Total Monetary Impact of All Recommendations
Open: $ 129,700,000.00
Closed: $ 9,810.00
Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic
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20-03075-138
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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: 1/24/2023
The under secretary for health direct the Medical Supplies Program Office to provide Veterans Integrated Service Network and VA medical facility chief logistics officers guidance on how to use and monitor the emergency and continuous supply strategies offered in prime vendors’ contingency plans to help mitigate acute emergency and continuous supply shortages during the current pandemic and future emergencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 1/6/2023
The 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.
Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds
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20-02967-121
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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: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to implement internal control procedures to ensure the completeness and accuracy of the data in VA’s reports to the Office of Management and Budget and to Congress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/6/2023
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to execute data validation procedures to make certain that reports to the Office of Management and Budget and to Congress can be traced back efficiently to the source transactions.
Inconsistent Human Resources Practices Inhibit Staffing and Vacancy Transparency
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20-00541-133
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Topics:  Staffing

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No. 1
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness develop and implement an enterprise wide plan to independently examine and validate the HR Smart position inventory.
No. 2
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness establish standard guidance to ensure positions are consistently approved, created, and maintained.
No. 3
Open Recommendation Image, Square
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
The OIG recommended the acting assistant secretary for human resources and administration/operations, security, and preparedness implement enterprise wide oversight mechanisms to monitor position management on a regular basis and ensure the HR Smart position inventory is properly maintained.
No. 4
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The OIG recommended the acting under secretary for health develop and implement a standardized national policy and procedures for the documentation and communication of staffing level approvals at VA medical facilities.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
The OIG recommended the acting under secretary for health publish detailed and prescriptive guidance establishing authoritative position management documents.
Use and Oversight of the Emergency Caches Were Limited during the First Wave of the COVID-19 Pandemic
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20-03326-124
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Topics:  COVID-19 ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health initiate efforts to revise or amend VHA Directive 1047 to clarify when changes to emergency cache activation procedures are appropriate, and develop the communication and documentation requirements for these situations to ensure all relevant parties—including medical facility directors and pharmacy chiefs—are aware of and comply with any changes to routine activation protocols as well as the responsibilities they maintain.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2023
The OIG recommended that the under secretary for health establish minimum time frames, for example by assessing Emergency Pharmacy Service’s data on the typical length of time it takes to replenish emergency cache inventory items, by which the Emergency Pharmacy Service initiates resupply orders to make sure caches are fully stocked with unexpired inventory.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/23/2023
The OIG recommended that the under secretary for health make sure that the Emergency Pharmacy Service and the Watch Office are maintaining accurate and complete records of emergency cache activations.
Program of Comprehensive Assistance for Family Caregivers: IT System Development Challenges Affect Expansion
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20-00178-24
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Topics:  System Development and Implementation

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, establish policies and procedures for joint governance by OIT and program offices on all information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology require the Office of Information and Technology to develop controls for making certain the program management review process is consistently enforced for future information technology projects to deliver and sustain the intended outcomes and to ensure underperforming projects are identified for evaluation by the Program and Acquisition Review Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, reevaluate the risk determination for the Caregiver Record Management Application and determine if the system should be set to a security categorization level of high based on the personal health information and other sensitive data maintained therein.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 11/8/2021
The OIG recommended the acting assistant secretary for information and technology establish VA wide policies and responsibilities for managing VA information technology projects under the Development Operations process.
Delay in a Patient’s Emergency Department Care at the Malcom Randall VA Medical Center in Gainesville, Florida
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20-03535-146
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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: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates processes and implements a requirement as necessary that Emergency Severity Index level 2 patients do not remain in the Emergency Department waiting room.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/22/2021
The North Florida/South Georgia Veterans Health System Director evaluates if additional quality reviews are needed due to failures identified in this report regarding the patient’s pre-code Emergency Department care, and takes action as indicated.
Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
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18-02496-157
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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: 6/5/2023
The Under Secretary for Health ensures that the Veterans Health Administration competency process for locum tenens, newly hired specialty care providers, and newly hired service chiefs is evaluated to confirm that the results of the assessment accurately reflects the clinical competency of providers who are privileged, and takes action, as indicated.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health reviews current Veterans Health Administration credentialing and privileging policies to assess guidance related to service chiefs’ ongoing professional practice evaluation and takes action, as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health reviews Veterans Health Administration policies to ensure that if facility leaders elect to incorporate pathology 10 percent peer reviews into the performance evaluations of a Pathology and Laboratory Medicine Service Chief, those reviews are performed by a peer without a conflict of interest and takes action, as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2022
The Under Secretary for Health evaluates the use and methodology of the Pathology and Laboratory Medicine Service 10 percent peer review for effectiveness as a quality management tool, and takes action, as indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration guidance related to amended pathology reports’ terminology, use, and entry of such reports into patients’ electronic health records, and revises guidance, as appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2022
The Under Secretary for Health confirms that provisions are included in the Veterans Health Administration record modernization program that ensure amended pathology report alerts are directed to designated facility staff and leaders.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The Under Secretary for Health evaluates Veterans Health Administration quality management processes related to external, non-VHA pathology consultant assessments and ensures that facility leaders, the specialty care provider, and requesting providers are notified of the results of such reviews and a tracking process is in place.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/13/2023
The Under Secretary for Health confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, & Preparedness to determine whether administrative action is warranted for Veterans Health Administration leaders who did not adequately perform their duties with respect to the issues within this report, and takes action, as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/5/2023
The Under Secretary for Health explores the development of a mandatory alcohol testing policy for individuals including healthcare workers who perform functions that would put patients at risk should the employee work while impaired.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2023
The Under Secretary for Health evaluates Veterans Health Administration’s guidance related to impaired healthcare workers and ensures that it addresses the circumstances under which alcohol and or drug testing may be performed; the extent of a retrospective review of care if one is indicated; and the availability of advisors who are knowledgeable on the management of an impaired provider, and takes action, as indicated.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director verifies that peer references obtained during the reappraisal and reprivileging processes are in alignment with VHA Handbook 1100.19, Credentialing and Privileging.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Veterans Health Care System of the Ozarks Director evaluates the psychological safety climate to ensure facility staff, patients, and the general public are empowered to report concerns and unsafe patient care without fear of reprisal and takes action, as needed.
Comprehensive Healthcare Inspection of the Battle Creek VA Medical Center in Michigan
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20-01267-148
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Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The Medical Center Director determines the reasons for noncompliance and ensures specific action items are recommended, implemented, and monitored when problems and opportunities for improvement are identified.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that an interdisciplinary committee reviews utilization management data as required.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete provider exit review forms within seven business days of licensed healthcare professionals’ departure from the medical center.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and effectiveness of pain management interventions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/5/2022
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 documented patient preference, within the required time frame.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women’s Health Advisory Committee meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2021
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. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures align with the manufacturers’ guidelines and instructions for use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete valid competency assessments prior to reprocessing reusable medical equipment.
Comprehensive Healthcare Inspection of the Chillicothe VA Medical Center in Ohio
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20-01268-143
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Topics:  Suicide Prevention ● Patient Safety ● Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analysis is reviewed quarterly by the Medical Staff Executive Council.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager monitors implemented root cause analysis action items for sustained improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff determines the reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a licensed healthcare professional’s first- or second-line supervisor correctly completes and signs an exit review form within seven business days of the professional’s departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Opioid Safety Review Board monitors the quality of pain assessment and effectiveness of pain management interventions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete suicide prevention training as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required Women Veterans Health Committee members are assigned and consistently attend meetings, and that the committee reports to the Medical Staff Executive Council.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures standard operating procedures are current, align with manufacturers’ guidelines/instructions for use, and are reviewed at least every three years or when there is a change.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/27/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that commercial airflow directional devices are used in areas where reusable medical equipment is reprocessed and stored.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that all Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employee competency assessments align with medical center standard operating procedures.
Compensation and Pension Proceeds Were Generally Handled Accurately but Some Were Delayed
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20-00817-123

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/14/2021
Implement a timeliness requirement or performance measure for handling proceeds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/27/2021
Develop oversight and monitoring procedures to ensure timely handling of proceeds.
Deficiencies in Reporting Reliable Physical Infrastructure Cost Estimates for the Electronic Health Record Modernization Program
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20-03178-116
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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

The executive director for the Office of Electronic Health Record Modernization should ensure an independent cost estimate is performed for program life cycle cost estimates including related physical infrastructure costs funded by the Veterans Health Administration.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/9/2022

The VA Assistant Secretary for Management and Chief Financial Officer  should ensure the Office of Programming, Analysis and Evaluation, or another office performing its duties, conducts independent cost 

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022

 The director of Special Engineering Projects for the Veterans Health  Administration’s Office of Healthcare Environment and Facilities Programs should develop a  reliable cost estimate for Electronic Health Record Modernization program-related physical  infrastructure in accordance with VA cost-estimating standards and incorporate costs for upgrade  needs identified in facility self-assessments and scoping sessions.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/20/2022

The director of Special Engineering Projects should also continuously update physical infrastructure cost estimates based on emerging requirements and identified project needs.

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

Ensure costs for physical infrastructure upgrades funded by the Veterans Health Administration or other sources needed to support the Electronic Health Record Modernization program are disclosed in program life cycle cost estimates presented to Congress.

Drug Interactions Related to a Patient Death, Marion VA Medical Center in Illinois
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20-03380-136
|
Topics:  Mental Health ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2022
The Marion VA Medical Center Director ensures that behavioral health staff provide, and document patient education including discussion of side effects and possible adverse drug-drug interactions during telephone encounters when medications are added or adjusted and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/27/2022
The Marion VA Medical Center Director confirms that behavioral health providers are communicating test results to patients and providing necessary clinical interventions as required by policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Marion VA Medical Center Director monitors implementation of Phase Four of the Psychotropic Drug Safety Initiative.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Marion VA Medical Center Director ensures that primary care providers enter return-to-clinic orders and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2022
The Marion VA Medical Center Director verifies primary care and behavioral health staff document contacts, attempted contacts, and letters sent when patients missed their appointments and monitors compliance.
Comprehensive Healthcare Inspection of the Cincinnati VA Medical Center in Ohio
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20-01276-131
|
Topics:  Patient Safety ● Medical Staff Privileging Credentialing ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, and Value Committee fully implements and monitors improvement actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that all applicable deaths are peer reviewed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2022
The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria for focused professional practice evaluations in practitioner profiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs document the results of focused professional practice evaluations in practitioner profiles.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs collect service-specific ongoing professional practice evaluation data.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff determines the reasons for noncompliance and ensures service chiefs recommend continuation of privileges based on ongoing professional practice evaluation data.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Clinical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend initiation and continuation of privileges.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2024

The Medical Center 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 medical center.

No. 10
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 clinicians complete suicide prevention safety plans in the expected time frame for patients with High Risk for Suicide Patient Record Flags.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Chief of Staff 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 plans for leave coverage if there is only one designated provider.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/12/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Advisory Committee meetings.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturer’s instructions for use.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2023
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that CensiTrac® is fully operational.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/13/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services maintains written records of weekly eyewash station function testing.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment receive monthly continuing education.
The Office of Field Operations Did Not Adequately Oversee Quality Assurance Program Findings
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20-00049-122

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/10/2023
Develop and implement a written plan to strengthen oversight of the quality assurance program for disability compensation benefits and monitor the plan to ensure identified deficiencies are adequately addressed.
Inadequate Resident Supervision and Documentation of an Ophthalmology Procedure at the Oklahoma City VA Health Care System in Oklahoma
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20-03886-141
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
The Oklahoma City VA Health Care System Director ensures a review of the clinic note for the patient who experienced temporary loss of vision and confirms that the level of supervision provided by the attending ophthalmologist is accurately reflected in the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/7/2021
The Oklahoma City VA Health Care System Director conducts a review to ensure that language used to document resident supervision accurately reflects the presence of the attending ophthalmologist and the degree of resident oversight provided and takes action as indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Oklahoma City VA Health Care System Director confirms that ophthalmology service procedures include a hand-off process to address attending coverage in situations when an attending ophthalmologist is unavailable to provide timely resident supervision.
Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia
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20-03593-140
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Under Secretary for Health ensures actions are taken to clarify and broadly disseminate adjudicator expectations for follow-up of an unreturned INV Form 41.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Louis A. Johnson Medical Center Director ensures Pharmacy Service utilizes the required Veterans Health Information Systems and Technology Architecture Automatic Replenishment System to record medication usage data and maintain the records for inventory accountability.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2021
The Veterans Integrated Service Network 5 Director conducts management reviews of the care of patients 1–10 as discussed in this report and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director reviews the availability and timeliness of endocrinology consults, and takes any corrective action needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Veterans Integrated Service Network 5 Director ensures evaluation of quality of care concerns or other irregularities (beyond hypoglycemia) of: cases provided by the OIG; cases that may otherwise be pertinent or concerning; and cases brought forward by patients and/or family members who express concerns or make other inquiries about care they received from Ms. Mays. As determined by the VISN, clinical experts external to the facility should be utilized when appropriate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director develops and disseminates guidance on clinical communication(s) to ensure that patient care and outcomes are routinely discussed in appropriate forums, such as interdisciplinary team meetings, and the discussions are documented.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures that close observation documentation is readily available in the electronic health record, and monitors for compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures clinical documentation reviews are completed timely for patient safety and continuity of care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director evaluates the factors and processes surrounding employees’ failures to report and follow up on the unexplained hypoglycemic events, and takes action to ensure appropriate reporting of actual or potential patient safety events, system vulnerabilities, or other unexpected events that offer opportunities for lessons learned.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson Medical Center Director requires that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2022
The Louis A. Johnson Medical Center Director ensures that the interdisciplinary mortality review workgroup meet as required with appropriate reporting through oversight council(s), and monitors for compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson Medical Center Director ensures that oversight and reporting practices align with Louis A. Johnson Medical Center policy requirements.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2022
The Under Secretary for Health determines the potential advantage of a rescue medication flagging system as an additional tool to evaluate unexplained adverse patient events, including but not limited to mortalities, and takes action as indicated.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Louis A. Johnson VA Medical Center Director takes action to prioritize and continue efforts to promote a strong culture of safety, such as periodic facility-wide refresher patient safety training or additional patient safety stand downs when indicated, and monitors for effectiveness.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2022
The Under Secretary for Health reevaluates how the Veterans Health Administration collects, reviews, and analyzes mortality data from VA facilities, and takes action to address identified gaps and weaknesses, as indicated.
Deficiencies in Leaders’ Responses to Lapses in Reusable Medical Equipment Reprocessing at the Chillicothe VA Medical Center in Ohio
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20-02265-100
|
Topics:  Patient Safety ● Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chillicothe VA Medical Center Director develops an oversight plan to address concerns regarding the employee’s compliance with Sterile Processing Services’ procedures as identified by facility and Veterans Integrated Services Network leaders and the Clinical Episode Review Team and confirms effective resolution.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2021
The Under Secretary for Health ensures that the Clinical Episode Review Team reviews the OIG-provided biomedical equipment manufacturer’s information for the automated endoscope reprocessor to determine if the information alters their determination regarding the potential risk to patients or the need for a large-scale disclosure and takes action as necessary.
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