Date Issued
|
Report Number
20-02830-05
|
Topics: COVID-19
● Suicide Prevention
All Reports
Date Issued
|
Report Number
19-08106-273
|
Topics: Patient Safety
● Mental Health
● Care Coordination
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/10/2021
The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and determines whether an institutional disclosure is warranted.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures Emergency Department and Inpatient Medical Unit staff performs vital sign assessment and monitors patients who received sedating medications.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nurses accurately document medication administration.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit staff implement patient restraint management according to the Charlie Norwood VA Medical Center policy, including documentation, physician orders, and education requirements.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nursing staff communicate with providers regarding patients’ refusal of treatment.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director strengthens Inpatient Medical Unit nicotine replacement therapy processes and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/16/2021
The Charlie Norwood VA Medical Center Director strengthens processes to include the patient, family members, or surrogate in informed consent procedures and treatment decisions, as appropriate, and monitors compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/16/2021
The Charlie Norwood VA Medical Center Director evaluates the inpatient mental health consult process, and addresses timeliness and completion of decision-making capacity consult requests, and monitors compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director consults with the Office of General Counsel regarding policies related to the management of patients presenting under a Form 1013 and advises policy and practices consistent with Georgia State mental health laws and takes action, as appropriate.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 11/18/2021
The Charlie Norwood VA Medical Center Director ensures staff adhere to inter-facility transfer policies and procedures, including accurate communication of patients’ restraint management status, and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director ensures that a consultation liaison psychiatrist is included on code gray teams at both divisions.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director evaluates inpatient mental health consult staffing and establishes a plan to ensure adequate staffing to complete consult requests as required without outpatient mental health appointment cancellations and monitors compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 6/8/2021
The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee reviews patient record flags and provides input into patients’ management to mitigate violence, as required by Veterans Health Administration, and monitors compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 8/16/2021
The Charlie Norwood VA Medical Center Director makes certain that staff receive education in code gray policy and procedures, including completion of the code gray evaluation form, and monitors compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 11/18/2021
The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee provides oversight of the code gray team activities, as required by Charlie Norwood VA Medical Center policy, and monitors compliance.
Date Issued
|
Report Number
18-04150-261
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/28/2021
The OIG recommends the VHA executive director for procurement ensures contracting officers are requesting preaward reviews for all sole source healthcare resource contracts with an annual value at or above $400,000 in keeping with the May 2018 revisions to VA Directive 1663.
No. 2
to Veterans Health Administration (VHA)
The OIG recommends the VHA executive director for procurement require an OIG preaward review for all interim contracts that exceed the $400,000 annual threshold.
No. 3
to Veterans Health Administration (VHA)
The OIG recommends the VHA executive director for procurement mandate an immediate postaward review for any sole source contract awarded on an interim basis as an emergency contract.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,101,555.00
Date Issued
|
Report Number
19-00226-245
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care Define the terms “verifiable usual and customary charges that are billed to payers other than VA” for the PC3/Choice contract claims.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure future community care programs have applicable definitions and guidance for claims without a Medicare or VA fee schedule rate to avoid reimbursements that pay at “billed charges.”
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care create a master usual and customary rate schedule to be used for reimbursement of community care claims without a Medicare or VA fee schedule rate to control program costs.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care provide parties responsible for reimbursing PC3/Choice and future community care program claims with usual and customary rate price schedules and a formal written policy on the proper application of those rates.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care establish controls for verifiable usual and customary rate payment methodology and establish a payment review process to ensure usual and customary rates are properly applied to the PC3/Choice and future community care program payments.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/5/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure payment-rate schedules used by the Plexis Claims Manager and future payment systems to support the PC3/Choice and future community care contracts are current, accurate, and complete to prevent overpayments.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/28/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure that the Office of Community Care determines an appropriate reimbursement process for the identified pass-through errors in this report.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/28/2021
The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure the Office of Community Care establishes formal policies and procedures to identify and recover overpayments from PC3/Choice third-party administrators for improperly billed claims.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 205,100,000.00
Date Issued
|
Report Number
19-07062-255
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 11/19/2020
The under secretary for benefits directs the Compensation Service to provide the Administration Results Report for each consistency study to the Office of Field Operations and to managers at all regional offices.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2021
The under secretary for benefits ensures the Office of Field Operations develops a process to monitor regional offices to ensure maximum employee participation in consistency studies.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2021
The under secretary for benefits makes certain the Office of Field Operations establishes a requirement for regional office managers to review consistency study results and develop a plan for corrective action based on the performance of their regional office.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 5/5/2021
The under secretary for benefits requires the Office of Field Operations to develop a follow-up process to confirm all corrective actions identified are completed by regional office managers.
Date Issued
|
Report Number
19-07854-272
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
20-00005-271
|
Topics: Staffing
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
19-07828-265
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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.
Date Issued
|
Report Number
17-00126-267
|
Topics: Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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.
Date Issued
|
Report Number
19-07103-252
|
Topics: Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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.
Date Issued
|
Report Number
18-00711-251
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
Date Issued
|
Report Number
20-01102-266
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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.
Date Issued
|
Report Number
20-01318-258
|
Topics: Patient Safety
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
20-01249-259
|
Topics: Staffing
Date Issued
|
Report Number
18-06039-229
|
Topics: Clinical Care Services Operations
● Appointment Scheduling and Wait Times
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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 Issued
|
Report Number
20-02825-242
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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.
Date Issued
|
Report Number
20-00058-250
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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.
Date Issued
|
Report Number
19-00227-226
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
Date Issued
|
Report Number
20-00131-243
|
Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
Date Issued
|
Report Number
20-00130-241
|
Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.