All Reports

Facility Leaders’ Response to Level 2 and Level 3 Pathology Reading Errors at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas
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21-01677-259
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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: 3/18/2022
The Under Secretary for Health clarifies the extent and content of documentation that should be included when circumstances require that a clinical disclosure be entered into the electronic health record.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2022
The Under Secretary for Health evaluates whether there should be a process for clinical provider(s) to communicate back to the Clinical Review Team when changes in patient health status indicate the need for consideration of institutional disclosures, and takes action as warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/17/2022
The Veterans Health Care System of the Ozarks Director implements a plan for completion of amended pathology reports for cases identified with level 2 pathology reading errors that is consistent with VHA Handbook 1106.01.
Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming
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21-00245-256
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Topics:  Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that all core members consistently attend Surgical Work Group meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that medical center staff monitor and evaluate inter-facility patient transfers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director determines the reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2021
The Medical Center Director determines the reasons for noncompliance and makes certain that the medical center has a current policy for reporting and tracking disruptive behavior.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Disruptive Behavior Committee documents patient notification of an Order of Behavioral Restriction and right to appeal in the Disruptive Behavior Reporting System.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/15/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Financial Efficiency Review of the Southeast Louisiana Veterans Health Care System in New Orleans
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20-00971-235
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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: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System develop a plan to work with the prime vendor to address having adequate stock from the facility’s formulary list in its warehouse to provide supplies when ordered.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System ensure logistics staff and the contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance issues.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System and the director of contracting for South Central VA Health Care Network Contracting Office 16 ensure approving officials and cardholders review their purchases and make sure strategic sourcing is used when it is in the best interest of the government.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System in coordination with the network purchase card program manager, require purchase cardholders to submit ratification requests to the director of contracting for Network Contracting Office 16 for any unauthorized commitments identified.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of contracting for South Central VA Health Care Network Contracting Office 16 ensure quarterly audits of the purchase card program are completed as required by the Veterans Health Administration standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2022
The OIG recommended the director of the Southeast Louisiana Veterans Health Care System ensure that the facility meets the Veterans Health Administration’s recommended inventory turnover rate of 12 per year, established by the National Pharmacy Benefits Management program office.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 192,070.00
Comprehensive Healthcare Inspection of the White River Junction VA Medical Center in Vermont
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21-00258-230

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2024

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

Comprehensive Healthcare Inspection of the Manchester VA Medical Center in New Hampshire
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21-00262-247
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Topics:  Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Surgical Work Group meetings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/9/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers identify the receiving provider on the VA Inter-Facility Transfer Form or facility-defined equivalent note.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff send the patient’s active medication list to the receiving facility during the inter-facility transfer.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/22/2022
The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between the sending and receiving facility.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Deficiencies in Administrative Actions for a Patient’s Inpatient Mental Health Unit and Community Living Center Admissions at the Tuscaloosa VA Medical Center in Alabama
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20-02907-254
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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: 10/31/2022
The Tuscaloosa VA Medical Center Director reviews informed treatment consent processes for the Inpatient Mental Health Unit and Community Living Center, confirms staff understanding of required processes, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures decision-making capacity evaluation completion and documentation, as required by Veterans Health Administration policy, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2022
The Tuscaloosa VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of Alabama commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director ensures adherence to Tuscaloosa VA Medical Center policies regarding against medical advice discharge procedures, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director consults with VA National Center for Ethics in Healthcare and reconsults the Office of General Counsel as needed to evaluate the appropriateness of the patient’s assigned surrogate decision-maker, and takes action as warranted.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2022
The Tuscaloosa VA Medical Center Director ensures staff completion of required patient advocate reporting and tracking processes, and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2022
The Tuscaloosa VA Medical Center Director evaluates the Community Living Center staff’s management of the patient’s correspondence request, including the Integrated Ethics consultation, and takes action as warranted.
Excess Purchase of Surgical Supplies and Improper Purchase Card Transactions at the New Orleans VA Medical Center in Louisiana
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20-00395-224
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Topics:  Supplies and Equipment ● Purchase Cards

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director account for the disposition of just over $125,000 in unaccounted for supplies in accordance with VA policies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director determine if any administrative action should be taken on just over $675,000 in unaccounted-for supplies listed in the report of survey.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure Federal Acquisition Regulation violations that resulted when purchase cards were used to acquire the approximately $1.9 million of supplies are reported to the Financial Services Center, and appropriate remedies, discipline, or penalties are taken in accordance with VA Financial Policy, Volume XVI.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/28/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director request the Veterans Health Administration’s head of contract activity ratify the approximately $1.9 million of identified split purchases.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure appropriate medical center employees coordinate with and obtain guidance from National Purchase Card Program staff when they are uncertain if they are properly using government purchase cards.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure leased operating room equipment is returned to the contractor as soon as possible if there are no plans to use that operating room for at least one year.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,145,291.00
Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System in Leeds
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21-00263-246

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022
The System Director evaluates and determines reasons for noncompliance and makes certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff document decisions to implement an Order of Behavioral Restriction and patient notifications in the Disruptive Behavior Reporting System.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2024

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

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The System Director evaluates and determines reasons for noncompliance and ensures the chair and members of the Employee Threat Assessment Team complete the required training.
Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans’ Hospital in Bedford, Massachusetts
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21-00260-232
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Topics:  Care Coordination ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024

The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent prior to patient transfer.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024

The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that staff send all pertinent medical records to the receiving facility during inter-facility transfers.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024

The Associate Director Nursing and Patient Care Services determines the reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between the sending and receiving facility.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/26/2022
The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/14/2024

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

No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Hospital Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required training.
Failure to Locate Missing Veteran Found Dead at a Facility on the Bedford VA Hospital Campus
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20-03465-243
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Topics:  VA Police

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No. 1
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)

The under secretary for health makes certain that policies and procedures are developed to require VA police, and other VHA staff as appropriate, to conduct searches for all persons who are reported missing on medical center campuses.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 8/31/2022

The executive director of the Office of Security and Law Enforcement updates VA Handbook 0730 with revisions clarifying VA police responsibilities with respect to searching for persons who are reported missing on VA property.

No. 3
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)

The assistant under secretary for health for operations, in consultation with the VA chief security officer, requires VA police chiefs at medical centers to obtain approval from the facility associate director or the medical center director prior to excluding a building or area of the medical center’s campus from regular patrols, and, if the building or area is subject to an enhanced-use lease, confirms with the Office of Enterprise Asset Management and the Office of General Counsel that the exclusion is not in conflict with the terms of the lease.

No. 4
Open Recommendation Image, Square
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)

For all medical centers that have property subject to enhanced-use leases, the assistant under secretary for health for operations, in consultation with the VA chief security officer, requires the medical center director or the director’s designee to meet with the assigned oversight monitor at the Office of Asset Enterprise Management, the designated local site monitor, and a representative of the Office of General Counsel at least annually—or sooner if there is a change of lease terms or facility leadership—to discuss the terms of the enhanced-use leases and the lessee’s and VA’s responsibilities with respect to the leased properties.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 1/28/2022
The executive director of the Office of Asset Enterprise Management includes a copy of the lease and VA Handbook 7454 with the designation memorandum sent to newly appointed lease site monitors.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 4/11/2023
The executive director of the Office of Asset Enterprise Management, in conjunction with the Office of General Counsel, reviews all active enhanced-use leases to determine whether any involve portions of buildings also occupied by VA, and, if so, whether they are clear regarding the maintenance and security obligations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Asset Enterprise Management (OAEM)
Closure Date: 4/11/2023
The executive director of the Office of Asset Enterprise Management modifies its existing Annual Oversight Compliance Certificate policies to include a review of VA’s performance with respect to any services VA is required to provide under the terms of enhanced-use leases.
Comprehensive Healthcare Inspection of the Oklahoma City VA Health Care System in Oklahoma
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21-00253-239
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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: 9/2/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete suicide safety plan training prior to developing suicide prevention safety plans.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/26/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System in Muskogee
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21-00251-212
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Topics:  Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct institutional disclosures for all sentinel events.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/13/2022
The System Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/28/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that required members regularly attend Surgical Work Group meetings.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
4. The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the transferring physician records all required elements on the Inter-Facility Transfer Form or facility-defined equivalent note prior to patient transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2022
The Chief of Staff determines the reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/1/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that all required members attend Disruptive Behavior Committee meetings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2023
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification for an Order of Behavioral Restriction in the Disruptive Behavior Reporting System.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/25/2023
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete the required training.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2023
The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Blue Water Navy Outreach Requirements Were Met, but Claims Processing and Procedures Could Improve
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20-03938-208
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Topics:  Claims and Appeals

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/2/2021
The OIG recommendated the under secretary for benefits develop and distribute procedures for when the ship locator tool provides results based on deck log coordinates for unlikely locations of herbicide exposure.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/7/2022
The OIG recommended the under secretary for benefits determine and execute additional actions to ensure employees processing Blue Water Navy claims understand how to accurately evaluate and decide herbicide-related medical conditions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/27/2021
The OIG recommended the undersecretary for benefits implement a plan for centralized regional offices to conduct local reviews on the accuracy of rating decisions involving herbicide-related medical conditions that will mitigate error trends identified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,200,000.00
Comprehensive Healthcare Inspection of the Providence VA Medical Center in Rhode Island
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21-00265-231
|
Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/5/2023
The Associate Director for Patient Care evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Comprehensive Healthcare Inspection of the VA Salt Lake City Health Care System in Utah
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21-00254-213
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Topics:  Care Coordination ● Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide prevention safety plans.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that inter-facility transfers are monitored and evaluated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff determines the reasons for noncompliance and ensures that appropriately-privileged providers complete or cosign the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to inter-facility patient transfers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that transferring physicians send active medication lists to receiving facilities during inter-facility transfers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2022
The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2020
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21-01502-240
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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: 10/4/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement action items recommended by the committees responsible for quality, safety, and value oversight functions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2022
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facilities peer review all applicable suicides.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that root cause analyses include a review of the underlying systems to determine where system redesigns might reduce risk.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2023
The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement approved root cause analysis action items and outcome measures show sustained improvement.
Mismanagement of a Patient at the Tomah VA Medical Center in Wisconsin
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20-01917-242
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Topics:  Patient Safety

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures that providers receive education regarding the management of alcohol withdrawal and delirium tremens, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director makes certain providers consider patients’ underlying cardiac risk prior to the order of haloperidol.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2022
The Tomah VA Medical Center Director conducts a comprehensive review of the patient’s cardiopulmonary resuscitation event to determine potential causes of failed oxygen delivery including systemic root causes and performance deficiencies, and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted and takes action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director implements actions recommended by the Out of Operating Room Airway Management workgroup, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director evaluates staff adherence to the Tomah VA Medical Center Policy MS-25, Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Protocol and the Standard Operating Procedure for Nursing Procedure, Symptom Triggered CIWA-Ar Protocol, and takes action to ensure compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2022
The Tomah VA Medical Center Director ensures inpatient medical unit providers and nursing staff compliance with patient restraint management, as required by to the Tomah VA Medical Center Policy, PCS-03, Restraint and Seclusion Use.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director monitors provider compliance with Tomah VA Medical Center Policy MS-06, Admission Criteria for Acute Medicine Unit.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director consults with the Office of General Counsel to ensure the Tomah VA Medical Center Policy PCS-SW-17 Emergency Detention is consistent with Wisconsin law.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director strengthens processes for staff to consider next of kin or family notification in the emergency detention of patients who may not comprehend their legal rights.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2022
The Tomah VA Medical Center Director ensures compliance with institutional disclosure procedures, as required by the Veterans Health Administration.
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