All Reports

Handling Administrative Errors at the Chicago VA Regional Benefits Office in Illinois
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20-00102-73
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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: 8/16/2021
The director of the Chicago VA regional benefits office ensure the errors identified by the review team are corrected.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/16/2021
The director of the Chicago VA regional benefits office monitor the effectiveness of the actions taken to improve the accuracy of administrative error corrections, and determine what additional measures, if any, are needed to make certain that claims processors understand how to apply national and local procedures for correcting administrative errors.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 67,000.00
Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Distribution Fee Invoicing
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19-06147-50
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Topics:  Supplies and Equipment ● Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/23/2024

Direct the Medical Supplies Program Office to implement procedures requiring chief logistics officers at Veterans Integrated Service Networks to monitor facility processes for verification and certification of distribution fee invoices to ensure invoice accuracy prior to payment by the Financial Services Center.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2025

Require Veterans Integrated Service Network directors to ensure their chief logistics officers develop distribution fee monitoring and review procedures for facility logistics audits and compliance reviews to ensure invoices are adequately reviewed, verified, and certified.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
Require Veterans Integrated Service Network directors to ensure facility chief logistics officers and contracting officer’s representatives review and update the election forms according to contract requirements and provide copies to the Medical/Surgical Prime Vendors for acknowledgment.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2025

Require Veterans Integrated Service Network directors to ensure facility contracting officer’s representatives verify that distribution fee rates match with those on the election forms and pricing schedule by comparing transaction data from the vendors to VHA-maintained transaction data, and reconcile payments as appropriate.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/25/2022
Require the Strategic Acquisition Center to develop and add modifications to the Medical/ Surgical Prime Vendor-Next Generation contract requiring prime vendors to provide reports to VA medical facilities with detailed medical and surgical transaction data, fee amounts, and fee percentage rates applied to each transaction on distribution fee invoices.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/25/2022
Require the Strategic Acquisition Center contracting officer to work with the Medical Supplies Program Office to ensure that Medical/Surgical Prime Vendor contracting officer’s representatives are assigned to each VA medical facility.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/2/2022
Require the Strategic Acquisition Center to appropriately modify the Medical/Surgical Prime Vendor contract to define annual facility purchase as well as adding a provision for paying the annual facility purchase amount based on the estimated total spend until year-end reconciliation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/2/2022
Require the Strategic Acquisition Center to also appropriately modify the Medical/ Surgical Prime Vendor contract to require the prime vendors—rather than the facility—to reconcile to annual facility purchases at the end of the year.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2023
Require the Medical Supplies Program Office to establish policy that clearly defines the source VA medical facilities should use to estimate their annual facility purchase amounts and determine the year-end amounts.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2024

Require VA medical facilities to review their on-site representative fees paid during fiscal year 2018 and future years to ensure they were paid based on the actual annual facility purchase amounts, consistent with the Medical/Surgical Prime Vendor-Next Generation contract, and reconcile payment discrepancies as appropriate.

Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,700,000.00
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 7: VA Southeast Network in Duluth, Georgia
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20-00130-86

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/3/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures the development of a written policy that establishes and maintains a comprehensive environment of care program at the Veterans Integrated Service Network level.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures an annual review of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement are submitted to executive leaders for review and approval.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to executive leaders.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2022
The Network Director evaluates and determines any additional reasons for noncompliance and makes certain the lead Women Veterans Program Manager completes annual site visits at each facility.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager completes assessments to identify staff education gaps related to women’s health and develops or adapts educational programs, materials, and/or resources where gaps are identified.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are posted within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Network Director evaluates and determines additional reasons for noncompliance and ensures that facility corrective action plans are developed within the required time frame.
VBA Did Not Consistently Comply with Skills Certification Mandates for Compensation and Pension Claims Processors
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20-00421-63

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits creates written guidelines for tracking, identifying, notifying, registering, and exempting individuals required to take skills certification tests.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits establishes a tracking mechanism to ensure all eligible individuals required to take tests are identified and notified of testing dates at least 30 days prior to test administration.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/25/2023
The under secretary for benefits provides an update to the plan submitted to Congress explaining why all employees and supervisors who have claims-processing functions listed in the original plan are not subject to skills certification testing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits implements a plan to ensure staff who failed their most recent skills certification test and remain in the same position are provided training from individual training plans to remediate the deficiencies in their skills and competencies.

No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/10/2024

The under secretary for benefits establishes an oversight plan to ensure training set out in approved training plans is provided to individuals who fail skills certification tests.

No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/5/2023

The under secretary for benefits notifies Congress of plans to take personnel actions against individuals who fail consecutive skills certification tests after remediation for the same positions in compliance with the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012.

The Office of Community Care’s Oversight of Non-VA Healthcare Claims Processed by Its Contractor
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19-06902-23
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Topics:  Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/7/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management directorate reevaluates all sample claims identified in this audit as not processed in accordance with Office of Community Care guidance, and takes appropriate corrective action as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2022
The OIG recommended the under secretary for health ensures there is a contract requirement that the contractor’s employees must follow Office of Community Care guidance for processing non-VA care claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2022
The OIG recommended the under secretary for health ensures the contractor’s standard operating procedures for claims processing are accurate and a mechanism is put in place to keep the contractor’s procedures updated to reflect current Office of Community Care claims processing procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The OIG recommended the under secretary for health ensures the Office of Community Care develops and implements clear controls for reviewing and updating, if necessary, the quality assurance surveillance plan requirements at least annually
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management personnel make full use of the established communication tracking tool.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/2/2021
The OIG recommended the under secretary for health ensures the Payment Operations and Management leaders provide timely training and additional guidance to their staff and the contractor’s employees on applying and using standardized denial and rejection reasons, and employees follow procedures to process claims with no authorizations to ensure consistent and accurate claims processing.
Mammography Program Deficiencies and Patient Results Communication at the Washington DC VA Medical Center
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20-00563-68
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Topics:  Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates documentation processes for entering the Breast Imaging-Reporting and Data System as primary diagnostic codes in the electronic health record and takes actions as necessary.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2023
The Washington DC VA Medical Center Director evaluates the processes for notification of mammography exam results by ordering providers and takes actions as necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director fully implements action plans for all issues listed in the September 2019 National Radiology Program Office site visit and monitors to completion.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2021
The National Radiology Program Office ensures mammography programs have a comprehensive standard operating procedure manual and confirms compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director develops and implements a comprehensive standard operating procedure manual covering critical technical, clerical, and administrative functions for the facility’s Mammography Program.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates the oversight and training processes for the facility’s Mammography Program medical support assistant and takes actions as necessary.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/1/2021
The Washington DC VA Medical Center Director evaluates mammography technology staff training processes and takes actions to ensure mammography technology staff receive training through a formalized program.
Biologic Implant Purchasing, Inventory Management, and Tracking Need Improvement
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19-07053-51
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Topics:  Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance and controls to clinic staff on making determinations to send purchase requests and consult notifications to the appropriate purchasing agents.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance to purchasing agents on how to effectively evaluate biologic implant purchase requests for the correct funding source.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Provide clarifying guidance to prosthetic agents to ensure they receive clinic staff consult notifications on all prosthetic purchases of biologic implants.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2022
Create a biologic implant cost code for general-purpose funds to improve funding accountability and potentially assist in ensuring all biologic implant use is tracked.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Direct the Procurement and Logistics Office to clarify guidance on the use of an approved inventory management system specific to biologic implants and the related VHA network, office, and facility staff responsibilities.
No. 6
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Monitor facility compliance with the use of an approved inventory management system for completeness and accuracy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2023
Direct the Procurement and Logistics Office to ensure logistics staff perform inventory reviews of biologic implants, as required.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2021
Monitor medical facility compliance with required reviews of on-site inventory.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/19/2024

Establish a structure for oversight responsibility that can provide guidance for tracking implanted biologics.

No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2024

Create policies and procedures for facilities to follow as they implement effective controls for tracking biologic implants.

No. 11
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
Establish standardized systems and requirements for facility staff to appropriately record necessary biologic implant attributes for accurate and accessible tracking of recipients to advance patient safety.
Reporting and Monitoring Personal Protective Equipment Inventory during the Pandemic
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20-02959-62
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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: 9/2/2021
Provide specific guidance for personnel in facilities and Veterans Integrated Service Network offices to report expired personal protective equipment supplies into the Response Monitoring Tool and refine the tool to allow the entry of expired supply levels on hand.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2022
Communicate effective verification measures for facilities and Veterans Integrated Service Networks to improve the reliability and consistency of reported personal protective equipment on-hand quantity and usage information.
VA Needs Better Internal Communication and Data Sharing to Strengthen the Administration of Spina Bifida Benefits
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20-00295-61

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Veterans Health Administration (VHA)
Closure Date: 4/12/2021
The OIG recommended that the under secretary for benefits and the under secretary for health formalize interagency sharing processes between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care on how data and information will be shared between both offices to prevent payments from continuing to deceased spina bifida beneficiaries.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Veterans Health Administration (VHA)
Closure Date: 4/12/2021
The OIG recommended that the under secretary for benefits and the under secretary for health take the following actions establish clear written guidance on sharing beneficiary data between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care to ensure all entitled beneficiaries are enrolled in health care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/7/2021
The OIG recommended that the under secretary for benefits institute standardized procedures to help the Veterans Benefits Administration’s national call center agents provide accurate and comprehensive information about spina bifida benefits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2022
The OIG recommended that the under secretary for health direct the Veterans Health Administration’s Office of Community Care to develop a process to ensure those beneficiaries who are not using the services for which they are eligible, or need assistance with locating those services, receive them.
VHA’s Response following Cardiac Catheterization Lab Closure at the Samuel S. Stratton VA Medical Center in Albany, New York
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19-09129-76
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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: 1/11/2022
The Under Secretary for Health should publish written guidance that clarifies roles and responsibilities of the national Cardiology program office, Veterans Integrated Service Networks, and Chief Medical Officers to review and opine on interventional cardiologist applicant’s qualifications for employment in those cases when facilities lack local interventional cardiology expertise and the facility’s Chief of Staff seeks subject matter expert opinion.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2022
The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/13/2021
The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.
Insufficient Oversight for Issuing Prosthetic Supplies and Devices
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18-00972-38
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Topics:  Patient Care Services Operations

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
Ensure Prosthetic and Sensory Aids Service business practice guidelines include specific requirements for conducting and properly documenting reviews of cloned and pending consults.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
Ensure Prosthetic and Sensory Aids Service staff develop a process to verify that consults include accessory and consumable supplies for prosthetic items prior to issuance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
Ensure Prosthetic and Sensory Aids Service establishes field consistency requirements for conducting program reviews and evaluations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2021
Ensure the executive director of the Prosthetic and Sensory Aids Service complies with existing policy for reviewing program assessments and evaluations and communicates review and evaluation results to the regional prosthetic representatives.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 79,200,000.00
Communication of Test Results and Oncology Scheduling Concerns at the Beckley VA Medical Center in West Virginia
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20-00339-69
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Topics:  Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Beckley VA Medical Center Director ensures that primary care providers comply with communicating laboratory test results to patients and documenting the discussion in accordance with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Beckley VA Medical Center Director ensures that the oncologist complies with facility scheduling and ordering policies including the Primary Care and Oncology Service Agreement.
Misconduct by a Gynecological Provider at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi
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20-01036-70
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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 initiates review of policies related to the role and training requirements of providers, including gynecologists, who conduct sensitive exams, to determine the need for the inclusion of trauma-informed care principles into training, policy, and practice.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures a review of policies related to the role and training requirements of chaperones for sensitive examinations and takes action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The South Central VA Health Care Network Director evaluates processes for tracking patient complaints, takes appropriate action to ensure that facility staff enter all complaints into the Patient Advocate Tracking System, and ensures that the data are tracked, trended, and analyzed to identify significant issues and trends.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Gulf Coast Veterans Health Care System Director ensures staff education of the Veterans Health Administration and Gulf Coast Veterans Health Care System policies related to employee misconduct and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2021
The Gulf Coast Veterans Health Care System Director reviews and evaluates policies related to administrative investigations, including fact-finding reviews and administrative investigation boards, to ensure such investigations are timely, objective, and documentation is sufficient to address the event under review.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/9/2021
The Gulf Coast Veterans Health Care System Director and facility leaders review the subject gynecologist’s conduct and quality of care provided and meet all Veterans Health Administration requirements for state licensing board and National Practitioner Data Bank reporting.
Comprehensive Healthcare Inspection of the Dayton VA Medical Center in Ohio
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20-01271-64
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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: 7/12/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs include the minimum specialty-specific criteria for professional practice evaluations of licensed independent practitioners.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs complete and document focused professional practice evaluations on all newly hired licensed independent practitioners and evaluation results are reviewed and documented by the Clinical Executive Board.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2021
The Medical Center Director determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2021
The Medical Center Director determines the reasons for noncompliance and makes certain that the Multidisciplinary Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/29/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that qualified providers conduct four follow-up visits within 30 days of a High Risk for Suicide Patient Record Flag placement.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2021
The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that clinicians complete patient safety plans within seven days before or after the current High Risk for Suicide Patient Record Flag date.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that life-sustaining treatment plans for patients who lack both decision-making capacity and a surrogate are referred to and reviewed by the assigned multidisciplinary committee.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/12/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines
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20-02779-59
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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: 9/14/2021
The VA Manila Outpatient Clinic Manager evaluates the current pharmacy ordering processes and takes action to reduce the frequency of pharmacy stock shortages.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2021
The VA Manila Outpatient Clinic Manager reviews the impact of nonworking hours, including holidays, on pharmacy processing delays and takes action as necessary.
False Statements and Concealment of Material Information by VA Information Technology Staff
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17-01980-201

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/27/2021
The Assistant Secretary for Information and Technology and Chief Information Officer confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the OIT program manager’s conduct.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2021
The Executive in Charge, Veterans Health Administration, confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the VHA employee’s conduct.
VA Needs to Comply Fully with the Geospatial Data Act of 2018
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20-02339-35
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Topics:  Information Technology and Security

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Enterprise Integration (OEI)
Closure Date: 7/6/2021
The acting assistant secretary for Enterprise Integration, in conjunction with the assistant secretary for Information and Technology, complies with requirement 3 in section 759(a) of the Geospatial Data Act to establish mandatory VA wide policies and responsibilities to promote the integration of geospatial data.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/9/2022
The assistant secretary for Information and Technology, in conjunction with the director of Enterprise Records Service, establishes a process to ensure geospatial data and activities are included on VA record schedules that have been approved by the National Archives and Records Administration in accordance with requirement 4 of the law.
Thoracic Surgery Quality of Care Issues and Facility Leaders’ Response at the C.W. Bill Young VA Medical Center in Bay Pines, Florida
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18-01321-56
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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: 6/30/2021
The Under Secretary for Health designates a thoracic specialty leader who has the authority to review all aspects of the personnel and management actions and can provide unbiased, authoritative, and timely guidance to facilities on the most clinically sound course of action when a thoracic surgeon’s practice or outcomes are under review, in order to ensure that VA provides high quality care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/30/2021
The Under Secretary for Health outlines general parameters and triggers for when facilities without local thoracic surgery expertise engage the thoracic specialty leader and how the thoracic specialty leader’s decisions and guidance will be documented.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/8/2022
The Under Secretary for Health clarifies Veterans Health Administration policy regarding providers’ responsibilities to document complications in operative reports.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The Under Secretary for Health reevaluates the eligible and mandatory assessment surgery cases reported to the National Surgery Office to determine if thoracic cases should be included in the list of mandatory assessment cases, and modifies the list as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The Under Secretary for Health defines expectations for peer review committee members whose cases are being reviewed to leave the room during those deliberations, provides guidance on how that recusal is to be annotated in the Peer Review Committee minutes, and updates Veterans Health Administration policy, as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The C.W. Bill Young VA Medical Center Director enhances processes to identify the existence of omissions or misrepresentations in operative note documentation and takes action based on identified deficiencies, if any.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The C.W. Bill Young VA Medical Center Director takes action to ensure that the surgeon is aware of, and complies with, expectations for professional communications and supporting staff to report adverse events and close calls.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/23/2021
The C.W. Bill Young VA Medical Center Director ensures the C.W. Bill Young VA Medical Center Surgical Work Group provides oversight as required by Veterans Health Administration policy and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The C.W. Bill Young VA Medical Center Director confirms processes are in place to ensure providers’ clinical privileges are specific to the facility and service, and are based on each provider’s clinical competence, and monitors for compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2021
The C.W. Bill Young VA Medical Center Director reviews whether the cases reflected in tables 1 and 2 in this report meet criteria for institutional disclosure and takes action as appropriate.
Deficiencies in Privileging a Urologist to Practice and Medication Management Processes at the VA Central Iowa Health Care System in Des Moines
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20-02359-52
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Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/16/2021
The VA Central Iowa Health Care System Director ensures sustained compliance of providers who order controlled substances maintaining an individual Drug Enforcement Administration registration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2021
The VA Central Iowa Health Care System Director ensures verbal medication orders given in the operating room comply with Veterans Health Administration and VA Central Iowa Health Care System policies to permit verbal orders in emergent situations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2021
The VA Central Iowa Health Care System Director ensures operating room verbal medication orders are entered in the Computerized Patient Record System pharmacy package in accordance with Veterans Health Administration and VA Central Iowa Health Care System policies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2021
The VA Central Iowa Health Care System Director ensures that verbal medication orders given in the operating room are reviewed by a pharmacist in accordance with VA Central Iowa Health Care System policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2021
The VA Central Iowa Health Care System Director ensures that controlled substance inspections include verification of medication orders for controlled substances removed from the operating room automated dispensing cabinet.
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