All Reports

Deficiencies in Pharmacy and Nursing Processes at the Southeast Louisiana Veterans Health Care System in New Orleans
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19-07854-272
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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: 3/9/2021
The Southeast Louisiana Veterans Health Care System Director educates pharmacy staff on the Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies related to unaffixed medication labels, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2022
The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff comply with the five rights of medication administration prior to administering medications.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff administer medications in accordance with physician orders as required by Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director confirms that the intensive care unit nursing staff comply with the Southeast Louisiana Veterans Health Care System policy for high-alert and high-risk medications.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director validates compliance with obtaining locked boxes to secure controlled substances for intravenous medications administered on the inpatient units.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The Southeast Louisiana Veterans Health Care System Director verifies that facility staff are aware of how to submit Joint Patient Safety Reports that contain complete and accurate information.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if peer reviews of relevant clinical staff are warranted.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if an institutional disclosure is warranted.
Nurse Staffing, Patient Safety, and Environment of Care Concerns at the Community Living Center within the San Francisco VA Health Care System in California
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20-00005-271
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Topics:  Staffing ● Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures that the Associate Director for Patient Care Services performs a comprehensive review of Community Living Center nurse staffing methodology, retrains the Nurse Staffing Methodology Coordinator, and develops staffing methodology processes that reflect the needs of the Community Living Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director continues efforts to recruit and hire for Community Living Center nursing assistants and ensures that alternate staffing strategies are consistently available to meet target nursing hours per patient day until optimal staffing is attained.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director confers with facility nursing leadership and the Office of Human Resource Management to identify and mitigate barriers to nursing assistant staff retention and recruitment and takes appropriate action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director consults with VA Sierra Pacific Network and VA Central Office to determine the number and status of approved Community Living Center operating beds and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/24/2021
The San Francisco VA Health Care System Director ensures a review of the episode of care related to Resident B’s elopement to determine if a formal quality management review is needed and takes action accordingly.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director evaluates the requirement for Community Living Center registry nursing assistant staff access to the electronic health record system, involving the Office of General Counsel and the Network Contracting Office 21 as appropriate and takes action if needed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures that Environmental Management Services provides Community Living Center staff a clear communication pathway to request assistance for all shifts and confirms its functionality.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director establishes comprehensive quality monitoring of the ongoing issue of the presence of flying insects in the Community Living Center, and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures that Community Living Center staff adhere to Veterans Health Administration hand-hygiene policies and ensures that corrective actions are initiated when hand-hygiene performance falls below established thresholds.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The San Francisco VA Health Care System Director ensures a comprehensive review of the registry agency agreement for performance, the provision of nursing assistants as requested, and determines if the agreement meets the needs of the Community Living Center.
Deficiencies in Provider Oversight and Privileging Processes at the Carl Vinson VA Medical Center in Dublin, Georgia
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19-07828-265
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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: 6/15/2021
The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with the oversight of medical staff, including those with possible physical impairments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/27/2021
The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with privileging policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with state licensing board reporting policies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2021
The Carl Vinson VA Medical Center Director evaluates concerns that the urologist has a possible physical impairment, consults with Human Resources, and takes action, if indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2021
The Carl Vinson VA Medical Center Director reviews current clinical care review processes, identifies areas of noncompliance with facility bylaws, and takes action to ensure compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/16/2021
The Carl Vinson VA Medical Center Director reviews current reduction of privileges processes, identifies areas of noncompliance, and takes action to ensure compliance with Veterans Health Administration policy.
Misuse of Funds, Improper Disposal of Equipment, and Destruction of Records
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17-00126-267
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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: 9/25/2020
The deputy undersecretary for health for the Office of Community Care, with the assistance of the Office of General Counsel as appropriate, ensures that the Office of Community Care’s Equal Employment Opportunity Office and its Revenue Operations group are correctly interpreting and complying with VA Handbook 5975.5 and VA’s Financial Policies and Procedures with regard to the administration of Special Emphasis Programs, including the purchase of food.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2020
The principal executive director and chief acquisition officer of the Office of Acquisition, Logistics and Construction and the deputy undersecretary for health for the Office of Community Care ensure that their staff are appropriately trained on requirements for compliance with VA Directive 6371 governing the destruction of temporary paper records.
The Veterans Health Administration’s Governance of Robotic Surgical System Investments Needs Improvement
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19-07103-252
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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: 3/21/2023
The OIG recommended the under secretary for health update the high cost, high tech medical equipment application to provide clearer instructions on preparing requests and providing supporting documentation for robotic surgical systems. The application and instructions should be disseminated to medical facilities, Veterans Integrated Service Networks, and responsible central office organizations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2023
The OIG recommended the under secretary for health establish controls to ensure information in high cost, high tech medical equipment applications is reviewed and validated before recommending final approval to the assistant deputy under secretary for health for administrative operations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/15/2022
The OIG recommended the under secretary for health evaluate the need and justification of the 10 robotic surgical systems at VA medical facilities that were acquired without approval by the assistant deputy under secretary for health for administrative operations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/14/2021
The OIG recommended the under secretary for health develop guidance for accurately and consistently coding robotic surgical procedures in the Veterans Health Information Systems and Technology Architecture.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2021
The OIG recommended the under secretary for health evaluate the need for the National Surgery Office to obtain robotic surgical procedure data from the system manufacturer to assess and validate the use of the systems at VA medical facilities.
Financial Controls Related to VA-Affiliated Nonprofit Corporations: Idaho Veterans Research and Education Foundation
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18-00711-251
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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: 3/31/2021
The Boise VAMC director confers with the Office of General Counsel to determine whether administrative action should be taken against the nonprofit’s current executive director concerning: (a) the processing of salary increases for the former executive director and herself without written authorization and performance evaluations as required by IVREF policies and (b) the failure to report the former executive director’s conduct regarding the salary increase to the board of directors.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Boise VAMC director makes certain the Idaho Veterans Research and Education Foundation board of directors implements controls requiring two or more responsible officials to provide oversight of all salary and pay rate changes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/3/2022
The Boise VAMC director ensures the Idaho Veterans Research and Education Foundation board of directors implements controls for the use of credit cards and the receipt, review, and reconciliation of credit card statements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2022
The Boise VAMC director establishes procedures that require the Research and Development Budget Office staff to review VA-affiliated nonprofit corporation invoices to confirm services were performed or goods were received in accordance with Intergovernmental Personnel Act agreements before approving invoices for payment.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/15/2022
The Boise VAMC director institutes procedures to make certain the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 112,400.00
Pharmacy Process Concerns and Improper Staff Communication at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia
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20-01102-266
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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: 4/26/2021
The Hunter Holmes McGuire VA Medical Center Director ensures prescriber education on prior authorization drug request consultation procedures including consult documentation options, urgency level communication, patient notification, and appeals processes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director promotes mental health prescribers’ utilization of the prior authorization drug request process in consideration of the medication plan most effective for each patient.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director ensures that electronic health records are reviewed for improper entries, and takes action as indicated.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/26/2021
The Hunter Holmes McGuire VA Medical Center Director conducts a review of staff improper electronic health record entries and electronic mail and consults with Office of Human Resources to determine if administrative action is warranted, and takes action as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Hunter Holmes McGuire VA Medical Center Director evaluates ways to improve the workplace relationships between Mental Health and Pharmacy Services staff, including consultation with the Veterans Integrated Services Network or the National Center for Organizational Development, and takes actions as appropriate.
Mismanagement of Emergency Department Care of a Patient with Acute Coronary Syndrome at the Robert J. Dole VA Medical Center in Wichita, Kansas
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20-01318-258
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Topics:  Patient Safety ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures that Emergency Department physicians receive training on the facility’s acute coronary syndrome protocol and verifies that ST-elevation myocardial infarction time goals are monitored, and improvements implemented as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director makes certain a facility policy that is applicable to all patient care areas outlines standardized processes for safe and timely interfacility transfers, including communication of appropriate transport services needed.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director conducts an analysis of the contributing factors that led to the delay in the patient’s interfacility transfer and takes action as necessary to improve identified deficiencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director ensures the newly implemented Emergency Department Interfacility Transfers policy is reviewed and updated to include improvements as data are obtained from the interfacility transfer analysis.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director makes certain that Emergency Department and Health Administrative Service staff are trained on the Emergency Department Interfacility Transfers policy, the updated service agreement between Cardiology and Emergency Departments, and interfacility transfer process and monitors the transfer process, including timeliness of transfers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures the Critical Care Committee evaluates all concerns identified during code events, makes recommendations for improvement, confirms actions are implemented, and assesses effectiveness of actions.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2021
The Robert J. Dole VA Medical Center Director ensures the Chief, Quality Management is a member of the Critical Care Committee, develops a process to address problems in obtaining the assistance of Emergency Medical Services or use of the 911 call system, and assesses the effectiveness of the process.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The VA Heartland Network Director reviews the peer reviews of physicians who provided care to the patient to determine if a focused clinical review by an independent reviewer is warranted and takes actions as necessary.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/24/2021
The Robert J. Dole VA Medical Center Director reviews the patient’s care provided in the Emergency Department and the circumstances of the interfacility transfer to determine if an institutional disclosure is warranted.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2021
The Robert J. Dole VA Medical Center Director ensures interfacility transfer data are collected, analyzed, and incorporated into the Robert J. Dole VA Medical Center’s quality management program as required by Veterans Health Administration policy.
Improved Oversight of Surgical Support Elements Would Enhance Operating Room Efficiency and Care
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18-06039-229
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Topics:  Clinical Care Services Operations ● Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider developing an oversight mechanism that includes the VISN Surgery Integrated Clinical Community Chair in the monitoring of medical facility operating room efficiency and surgical support element problems and ensures VISN Directors hold medical facilities accountable when these problems persist and reduce operating room efficiency.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider periodically analyzing two to three years of operating room efficiency data to identify medical facilities that have not consistently met National Surgery Office efficiency goals and assess surgical support element problems impacting patients and operating room efficiency.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office clarify the intent of the current utilization measure and assess other utilization measures other than staffing.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2020
The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office gather as part of its capacity measure information about operating room closures or reduced usage, including the reasons for the closures or curtailment of surgeries.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2022
The OIG recommended the Under Secretary for Health consider identifying surgical support element best practices used by efficient facilities and ensure less efficient medical facilities, where appropriate, implement these practices to address problems, reduce surgical cancellations and delays, and minimize patient risks.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/1/2021
The OIG recommended the Under Secretary for Health consider requiring medical facility surgical work groups to discuss the National Surgery Office Efficiency goals and their facility’s performance with support services, such as logistics, sterile processing service, and environment management service, at least quarterly and ensure they all work proactively and collaboratively to address surgical support element problems.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 30,000,000.00
Date of Receipt of Claims and Mail Processing During the COVID-19 National State of Emergency
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20-02825-242
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Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/12/2020
Determine what additional actions are needed to make certain that staff understand how to accurately apply the most current guidance to the date of receipt recorded for claims received during the national state of emergency and implement those actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/24/2022
Conduct a review to ensure claims received and completed from March 1, 2020, had the correct date of entitlement applied.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/12/2020
Reevaluate guidance for the date of receipt recorded for claims without a postmark received during the national state of emergency.
Comprehensive Healthcare Inspection of Veterans Integrated Service Network 12: VA Great Lakes Health Care System in Westchester, Illinois
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20-00058-250

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Network Director evaluates and determines the reasons for noncompliance and ensures that the Sterile Processing Services Management Board conducts Veterans Integrated Service Network-led facility reusable medical equipment inspections.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
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 provided to executive leaders.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Network Director determines the 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. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2021
The Network Director determines the reasons for noncompliance and ensures that Veterans Integrated Service Network-led reusable medical equipment facility inspection corrective action plans are developed and tracked until closure.
The Veterans Benefits Administration Inadequately Supported Permanent and Total Disability Decisions
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19-00227-226

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 7/5/2022
The under secretary for benefits ensures the adjudication procedures manual is updated for consistency with all applicable laws, regulations, and policies related to permanent and total determinations in consultation with the office of general counsel.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/2/2022
The under secretary for benefits ensures decision-making staff support their permanent and total status decisions in the Reasons for Decision section of the rating decision by describing the evidence used to support their conclusions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/9/2022
The under secretary for benefits replaces the title and standardized language of “Dependents’ Educational Assistance under 38 U.S.C. Chapter 35” in rating decisions to clearly state that permanent and total status is being considered.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2023
The under secretary for benefits ensures appropriate training is provided to decision-making staff based on the changes made to permanent and total procedures related to Recommendations 1, 2 and 3, and monitor the effectiveness of that training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 122,000,000.00
Comprehensive Healthcare Inspection of the Central Alabama Veterans Health Care System in Montgomery
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20-00131-243
|
Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that final peer reviews are completed within 120 calendar days from the date a peer review is required, and any necessary extensions are approved in writing by the System Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that the Interdisciplinary Peer Review Panel provides quarterly analysis summaries to the Medical Executive Council.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager includes all required elements in root cause analyses and properly documents root cause analyses in the VHA Patient Safety Information System.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within the required time frame.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee provides feedback to staff who submit patient adverse event reports that result in root cause analysis actions.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete focused and ongoing professional practice evaluations of licensed independent practitioners.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service- or section-specific ongoing professional practice evaluation data.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the healthcare system.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that healthcare system managers maintain a safe and clean environment by identifying and resolving environmental deficiencies found during environment of care rounds.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
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, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing for patients on long-term opioid therapy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
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. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up with patients receiving long-term opioid therapy includes an assessment of adherence to the pain management plan of care.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up with patients receiving long-term opioid therapy includes an assessment of intervention effectiveness.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up appointments within the required time frame for patients flagged as high risk for suicide.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The System Director evaluates and determines any additional reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The System Director evaluates and determines any additional reasons for noncompliance and makes certain that all required members consistently attend Women Veterans Health Committee meetings and the committee reports to executive leaders.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that healthcare system staff collect and track the required women veterans quality assurance data.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis to the Veteran Integrated Service Network Sterile Processing Services Management Board.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief, Engineering Services conducts annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that commercial airflow directional devices are used in areas where reusable medical equipment is reprocessed and stored.
No. 28
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2022
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
No. 29
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Reusable Medical Equipment Coordinator completes competency assessments for all staff reprocessing reusable medical equipment.
No. 30
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
Comprehensive Healthcare Inspection of the Birmingham VA Medical Center in Alabama
|
20-00130-241
|
Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Medical Center Director determines the reasons for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that the service chief includes the minimum pathology-specific criteria for focused professional practice evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific criteria for ongoing professional practice evaluations.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a licensed healthcare practitioner’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of departure from the medical center.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that medical center managers keep furnishings and equipment safe and in good repair.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that Environmental Management Services staff separate clean and dirty equipment, devices, and supplies.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director evaluates and determines any additional reasons fornoncompliance and ensures that medical center managers maintain safe, functional,and clean patient care areas.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The Associate Director evaluates and determines any additional reasons fornoncompliance and ensures that staff secure protected health information withinlaboratory transport containers.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
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 untreated substance abuse, unstable psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain providers document justification for prescribing opioids and benzodiazepines concurrently.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2021
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. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans are completed within seven days before or after the High Risk for Suicide Patient Record Flag designation.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans include all required elements for patients with High Risk for Suicide Patient Record Flags.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/24/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2021
The Associate Director for Patient/Nursing Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee
|
19-09493-249
|
Topics:  Suicide Prevention ● Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director evaluates the current process for patients discharged from the Emergency Department who need to be seen the same day in the Outpatient Mental Health Clinic for medication management, establishes a clear referral process to the Outpatient Mental Health Clinic, and verifies that patients receive the care needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director reviews the Emergency Department Mental Health Handbook and defines a clear process for medication management in the Emergency Department, and ensures that patients receive same day psychiatric medication management when indicated.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2022
The Memphis VA Medical Center Director evaluates the current process for Emergency Department physicians to refer patients to the Emergency Department mental health provider for a mental health assessment and verifies that patients who require mental health provider assessment receive the care needed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director reviews the current medication reconciliation processes in the Emergency Department and Primary Care Clinics and verifies that providers complete and document medication reconciliation in accordance with policy and makes changes as necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director assesses the Outpatient Mental Health Clinic check-in process and verifies mental health patients are registered, triaged, and receive mental health services as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center ensures that patients are offered the option of community care consult, as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director evaluates the outpatient consult process and verifies that providers manage discontinued consults appropriately.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The Memphis VA Medical Center Director evaluates the process for community care clinical oversight, clarifies who has responsibility for coordinating care for patients receiving mental health in the community, and verifies that patients receive authorized community mental health care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2022
The Memphis VA Medical Center Director evaluates the process for timely retrieval of medical records from community care providers, verifies the medical records are uploaded into patients’ electronic health records, and takes action as necessary.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/11/2021
The Memphis VA Medical Center Director evaluates the clinical review process for community care authorizations, ensures staff are trained on the process, verifies that authorizations have clinical delegate review, and are processed timely.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director reviews the complaint reporting, responding and tracking processes and ensures that complaints are addressed, resolved, and documented in accordance with current facility policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2021
The Memphis VA Medical Center Director ensures leaders and supervisors are trained on initiating and conducting a fact finding.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/3/2020
The Memphis VA Medical Center Director considers conducting further review to address the differing accounts of the Emergency Department physician and Emergency Department mental health provider regarding the patient referral to ascertain whether the Emergency Department failed to follow facility policy, and takes action if needed.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director ensures that responsible staff receive training on completing behavioral autopsy reports as required by the Veterans Health Administration Behavioral Health Autopsy Program and verifies that behavioral autopsies are completed in accordance with policy.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/3/2021
The Memphis VA Medical Center Director reviews the issue brief reporting requirements with supervisors and ensures timely issue brief reporting for patients who die by suicide.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The Memphis VA Medical Center Director ensures that staff who conduct root cause analyses are trained on the guidelines for interviewing individuals vital to the root cause analysis charter and identified processes, and verifies the root cause analysis interview guidelines are followed.
Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center in Alabama
|
20-00130-194
|
Topics:  Suicide Prevention

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director determines the reason(s) for noncompliance and ensures egresses are free of blockages.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director determines the reason(s) for noncompliance and ensures damaged wheelchairs are repaired or removed from service.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that the Suicide Prevention Coordinator ensures completion and documentation of at least five outreach activities each month.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers document all required elements of goals of care conversations.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director evaluates and determines reason(s) for noncompliance and certifies that the multidisciplinary committee responsible for life-sustaining treatment decision reviews include three or more different disciplines and at least one member from the medical center’s Ethics Consultation Service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Medical Center Director determines the reason(s) for noncompliance and ensures that the multidisciplinary committee reviews life-sustaining treatment plans for patients who lack decision-making capability and do not have a surrogate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations maintains an accurate file of all reusable devices that includes current manufacturers’ instructions for use.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2021
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and makes certain that the CensiTrac® instrument tracking system is installed and operational.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Associate Chief Nurse of Operations reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services areas are cleaned as scheduled.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2021
The Associate Director for Nursing and Patient Care Services determines the reason(s) for noncompliance and ensures that Sterile Processing Services staff receive competency assessments for reprocessing reusable medical equipment.
Financial Management Practices Can Be Improved to Promote the Efficient Use of Financial Resources
|
18-03800-232
|
Topics:  Financial Management

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2025

The OIG recommended the executive in charge, Office of the Under Secretary for Health, establish financial controls, such as key performance indicators, that align with medical center operations and can be used to assess the efficient use of operating funds.

No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/2/2020
Specify the accountable Veterans Health Administration office responsible for establishing financial controls to ensure Veterans Health Administration’s financial management activities promote the efficient use of funds at Veterans Integrated Service Networks.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/6/2021
The OIG recommended the executive in charge, Office of the Under Secretary for Health, require the Veterans Health Administration to establish and publish organizational charts that identify the appropriate financial management reporting lines of authority and to develop familiarization training on the reporting lines of authority at the VISN and medical center levels, as appropriate.
Appointment Management During the COVID-19 Pandemic
|
20-02794-218
|
Topics:  COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health develop and clearly communicate a well defined strategic plan to all medical facilities for rescheduling patients and provide oversight particularly to those facilities with the highest rates of canceled appointments with no evidence of follow up or tracking.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health develop a mechanism to monitor facilities’ progress with following up on all cancellations to ensure facilities are not solely relying on COVID annotations or cancellation source classifications when rescheduling.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/21/2021
The OIG recommended the under secretary for health ensure that facilities take appropriate follow up action on canceled or discontinued consults.
Comprehensive Healthcare Inspection of the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois
|
20-00064-238
|
Topics:  Medical Staff Privileging Credentialing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures improvement action items recommended by the Quality Council are fully implemented and monitored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain the Patient Flow Committee meeting minutes reflect documentation, implementation, and evaluation of action items.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures service chiefs document focused professional practice evaluation results in provider profiles.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of initially granted privileges.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation criteria.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/18/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete licensed independent practitioners’ ongoing professional practice evaluations.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the center.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers repair or remove damaged wheelchairs from service.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers maintain a safe and clean environment.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures adequate privacy is provided in patient examination rooms at the Evanston VA Clinic.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures the information technology room at the Evanston VA Clinic is secure and restricted to authorized personnel.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Healthcare Center Director determines the reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures that clinicians at community-based outpatient clinics provide integrated mental health services for women veterans.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when clinics have only one provider.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures the Women’s Health Medical Director collects, tracks, and reports quality assurance data.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services aligns standard operating procedures with manufacturers’ guidelines and instructions for use.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services enters all equipment into the CensiTrac® Instrument Tracking System.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff conduct annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Engineering Service or designee conduct and maintain the record of weekly eyewash station function testing.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2021
The Associate Director for Facilities Support determines the reasons for noncompliance and makes certain the Environmental Management Supervisor develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that endoscopes are properly stored by Sterile Processing Services and clinical staff.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/29/2021
The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
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