All Reports

Construction Project Management at the Ralph H. Johnson VA Medical Center in Charleston, South Carolina
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18-01944-214

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2019
The OIG recommended the director of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina, ensure a process is established requiring that the Veterans Integrated Service Network 7 capital asset manager be informed, prior to construction contact awards, if construction is not planned to start within 150 days after contract awards, so that prudent decisions can be made in a timely manner regarding project funds.
Workload Management Challenges Identified at the Salt Lake City, Utah, Fiduciary Hub
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19-06565-217

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
The Director of the Salt Lake City Regional Office ensures the Fiduciary Hub workload management plan establishes timeliness goals for the various action mail tasks.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2020
The Director of the Salt Lake City Regional Office makes certain fiduciary hub managers measure performance and monitor adherence to timeliness goals for action mail tasks once established.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
The Director of the Salt Lake City Regional Office establishes a requirement within the Fiduciary Hub workload management plan for routinely reviewing and resolving duplicate action mail tasks.
Leadership Failures Related to Training, Performance, and Productivity Deficits of a Provider at a Veterans Integrated Service Network 10 Medical Facility
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19-06429-227

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2020
The Veteran Integrated Service Network 10 Medical Facility Director ensures the Credentialing and Privileging process for primary source verification of foreign education is performed and documented in accordance with Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2020
The Veteran Integrated Service Network 10 Medical Facility Director ensures that the Credentialing and Privileging process for verifying and accepting professional references meets sufficiency standards in accordance with Veterans Health Administration guidance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2020
The Veteran Integrated Service Network 10 Medical Facility Director ensures that the Focused Professional Practice Evaluation process used to determine technical competence and skills meets Veterans Health Administration requirements.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
The Veteran Integrated Service Network 10 Director evaluates whether the decision to reappoint the surgeon referenced in this report was improperly influenced by the Chief of Staff’s resolve to retain the services of the surgeon’s spouse in a sub-specialty position, and take action, if indicated.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
The Veteran Integrated Service Network 10 Medical Facility Director coordinates with Veterans Integrated Service Network 10 or other resources to assist and support sole providers with performance deficits.
Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma
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18-06510-222

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/6/2021
The chief of staff makes certain that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff makes certain that all focused professional practice evaluations include clearly defined time limitations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff confirms that clinical managers share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors clinical managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The associate director confirms that unit supervisors remove clean and sterile packaged items from shipping cartons and corrugated boxes prior to stowing in clean or sterile storage areas and monitors unit supervisors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director ensures that the military sexual trauma coordinator tracks and monitors the screening, referral, and treatment services provided to veterans and monitors coordinator’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/26/2021
The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the risks/benefits, potential interactions, and side effects of newly prescribed medications and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff ensures clinicians maintain and communicate accurate patient medication information in patients’ electronic health record and reconcile medications and monitors clinicians’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2021
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director makes certain that the Women Veterans Health Committee reports at least quarterly to the Medical Executive Committee.
State Prescription Drug Monitoring Programs Need Increased Use and Oversight
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18-02830-164

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2021
Develop national processes to oversee medical facility compliance with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, and coordinate the possible automated information technology solutions and inter-office and -disciplinary communications necessary to improve prescription drug monitoring program monitoring and usage in Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/13/2021
Update the Pain Management and Opioid Safety training course to specifically address VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, query requirements and recommendations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
Ensure VA clinicians who prescribe opioids take the Pain Management and Opioid Safety training once, with annual refresher training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Add an addendum to VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, that references the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain and ensure VA clinicians are educated and receive annual training on the Clinical Practice Guideline, to include the Centers for Disease Control and Prevention’s recommended frequency for prescription drug monitoring program queries based on the patients’ risk factors.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Direct Veterans Integrated Service Networks and their VA medical facilities to ensure local policies are consistent with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/11/2021
Develop automated information technology solutions to facilitate clinicians’ access toprescription drug monitoring program query information and reinforce the need tocomplete minimum annual VA-required prescription drug monitoring program queries.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2020
Ensure non-VA care clinicians are in good standing and have a current state medical license that requires adherence to their state’s prescription drug monitoring program query requirements; adhere to the Veterans Affairs Opioid Safety Initiative Guidelines, including guidelines for prescription drug monitoring program queries; and are monitored to ensure appropriate corrective actions are taken if their prescribing practices are found to be inconsistent with VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Ensure Veterans Integrated Service Networks implement an effective prescription drug monitoring program oversight process that includes the review of compliance rates with medical facility directors.
Alleged Care Delays and Inadequate Instrument Precleaning at the New Mexico VA Health Care System, Albuquerque
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18-03526-230

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director ensures that patients denied a Veterans Choice Program referral are informed of their rights to appeal, that facility policy is consistent with Veterans Health Administration requirements, and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director verifies that the Ophthalmology and Optometry Departments’ consult management and scheduling practices are consistent with Veterans Health Administration patient indicated date timeframe requirements, incorporates patient preference, and includes receiving provider review of consults, and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director makes certain the Ophthalmology and Optometry Departments’ clinical and administrative staff receive training regarding Veterans Health Administration requirements of consult management and scheduling practices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director reviews the Ophthalmology Department’s eye cataract intake surgery scheduling practice and ensures that overall timeliness is consistent with Veterans Health Administration directives, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The New Mexico VA Health Care System Director conducts a timeliness review of the authorization process for non-VA Care routine eye appointments, including diabetic eye examinations, and implement action plans if the process fails to adhere to Veterans Health Administration directives.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director ensures the Gastroenterology Department’s consult management practices are consistent with Veterans Health Administration scheduling requirements for patient indicated dates, and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director establishes a routine review of Gastroenterology Department consult performance measures and a method to monitor identified deficiencies consistent with Veterans Health Administration requirements.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2020
The New Mexico VA Health Care System Director evaluates whether test results within the past 12 months, ordered by the Gastroenterology Department were communicated to patients according to Veterans Healthcare Administration and facility policy, and takes action as necessary based on the results of the evaluation.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director reviews facility policy for the ordering and reporting of test results to be in alignment with Veterans Health Administration directives and completes revisions, if needed.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director ensures that Gastroenterology Department-ordered test results are communicated timely in accordance with Veterans Health Administration and facility policy and the timeliness is monitored through the ongoing peer review process as required by facility policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The New Mexico VA Health Care System Director ensures that the Gastroenterology Department Service Chief develop a process for delegating responsibility and accountability for test results and follow-up when multiple providers are involved, and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director ensures documented endoscope precleaning training for Gastroenterology Fellows, and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director verifies that documentation of endoscope precleaning competencies for Gastroenterology Fellows is consistent with Veterans Health Administration requirements.
Boston, Massachusetts, VA Regional Office Supervisor Incorrectly Processed Work Items
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19-07350-192

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/18/2020
The director of the Boston VA Regional Office reviews and corrects all work items that were cancelled or cleared by the supervisor that are likely to result in adjustments to recipients’ benefit payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2019
The director of the Boston VA Regional Office confers with regional counsel to determine the appropriate administrative action to take, if any, against the supervisor.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2020
The director of the Boston VA Regional Office implements a plan to ensure internal controls for assessing the quality of claims processed by supervisors.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 84,400.00
Quality of Care and Patient Safety Concerns on the Acute Behavioral Health Unit at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
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18-00777-224

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that providers understand the importance of monitoring for cardiac changes, drug-drug interactions, and signs of oversedation when initiating patients on methadone.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director monitors that providers and clinical staff effectively and directly communicate with one another when providing complex patient care.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director confirms that the issue brief submitted on the identified patient contains accurate information.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director reviews the root cause analysis related to the identified patient to determine if the team composition compromised the integrity of the root cause analysis and take appropriate action if necessary.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that root cause analysis team compositions include appropriate staff and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director considers Peer Review for Quality Management for the additional two providers identified in this report.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that Unit 7E staff are knowledgeable of the observation policy, and nursing leaders are monitoring staff compliance when assigned rounding responsibilities.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director completes actions initiated or taken to resolve identified deficiencies that contributed to the events discussed in this report, and monitors for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director certifies that providers receive ongoing education on the required elements of a signed written consent prior to the initiation of methadone and ensures that providers comply with VA policy and monitors for compliance.
Sole-Source Service Contracting at Regional Procurement Office West Needs Improvement
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18-01836-185

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2019
The OIG recommended the Executive Director, VHA Procurement, ensure awareness of approval procedures and the requirement to prepare a written justification and approval document for sole-source contracts,
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2020
The OIG recommended the Executive Director, VHA Procurement, establish procedures to help ensure all justification and approval documents are prepared and approved by the appropriate authority.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2019
The OIG recommended the Executive Director, VHA Procurement, review the actions of contracting personnel involved in the cited contracts and determine whether administrative actions are warranted.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,034,026.00
Sole-Source Service Contracting at Regional Procurement Office East Needs Improvement
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18-01836-184

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/17/2019
The OIG recommended that the executive director, VHA Procurement ensure awareness of approval procedures and the requirement to prepare a writtenjustification and approval document for sole-source contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The OIG recommended that the executive director, VHA Procurement establish procedures to help ensure all justification and approval documents areprepared and approved by the appropriate authority.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The OIG recommended that the executive director, VHA Procurement review the actions of contracting personnel involved in the cited contracts anddetermine whether administrative actions are warranted.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The OIG recommended that the executive director, VHA Procurement establish formal coordination with the requiring activity to ensure adequate time isallotted for soliciting and awarding recurring services competitively.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,245,166.00
Security and Access Controls for the Beneficiary Fiduciary Field System Need Improvement
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18-05258-193

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/26/2020
The assistant secretary for information and technology, in conjunction with the under secretary for benefits, reevaluate the risk determination for the Beneficiary Fiduciary Field System and determine if the system should be set to a security categorization level.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/26/2020
The assistant secretary for information and technology, in conjunction with the under secretary for benefits, perform a risk assessment of access levels to beneficiary and fiduciary records, based upon the least privilege principle, and regularly review access to ensure that principle is enforced.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 8/26/2020
The assistant secretary for information and technology ensures audit logs within the Beneficiary Fiduciary Field System allow for management tracking of end-user access in order to reduce unauthorized browsing and the risk of data theft due to malicious activity.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/13/2020
The under secretary for benefits ensures field examiners submit reports with a cursory lock engaged to protect their data integrity and to prevent separation of duties issues.
Problems Were Identified on One Regional Procurement Office Central Ambulance Service Contract
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18-01836-183

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/12/2019
The OIG recommended that the executive director, VHA Procurement ensure awareness of approval procedures for justification and approval documents for sole source contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The OIG recommended that the executive director, VHA Procurement establish formal coordination with the requiring activity to ensure adequate time is allotted for soliciting and awarding recurring services competitively.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,227,493.00
National Review of Hospice and Palliative Care at the Veterans Health Administration
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17-05251-194

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/29/2021
The Under Secretary for Health ensures the development and implementation of a consistent and standardized approach for hospice and palliative care documentation, consult management, and coding.
Accuracy of Claims Decisions Involving Conditions of the Spine
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18-05663-189

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Implement a plan to conduct a focused analysis of claims processor compliance with the requirements set forth by recent court decisions regarding examiner opinions and formulate a plan to review and take corrective action on affected claims if deemed necessary based on the results of that review.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/24/2023
Develop a plan to update the rating schedule to establish more objective criteria for each level of evaluation for peripheral nerves.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Review all sections of the procedures manual related to peripheral nerve disability evaluations and develop a plan to make updates and clarifications where applicable.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/6/2020
Review the disability benefits questionnaire forms for conditions of the spine and determine whether updates are needed to help ensure more accurate and consistent claims decisions.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Update the Evaluation Builder tool to help users provide more accurate, comprehensive, and consistent information for claims decisions involving the spine and peripheral nerves.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 64,800,000.00
Facility Leaders’ Oversight and Quality Management Processes at the Gulf Coast VA Health Care System in Biloxi, Mississippi
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17-03399-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Veterans Integrated Service Network 16 Director oversees implementation of recommendations directed to the Gulf Coast VA Health Care System Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that providers with previous licensure issues or malpractice cases meeting the Veterans Health Administration indicated threshold for Veterans Integrated Service Network Chief Medical Officer review, are approved by the Veterans Integrated Service Network Chief Medical Officer prior to appointment of the provider to the medical staff as required by Veterans Health Administration policy and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that Focused and Ongoing Professional Practice Evaluations are completed in accordance with Veterans Health Administration policy and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The Gulf Coast VA Health Care System Director ensures that actions are taken to ensure processes are followed to review and report providers, when indicated, to the National Practitioner Data Bank and state licensing boards in the timeframe required by Veterans Health Administration policy and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director reviews the circumstances surrounding the failure to report the surgeon to all licensing boards in states where the surgeon held active licenses in December 2017 and takes action, if necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that the Executive Committee of the Medical Staff’s meeting minutes provide sufficient detail to allow tracking of medical management decisions and problem solving and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2020
The Gulf Coast VA Health Care System Director determines the scope of previously administratively closed incomplete notes in patient electronic health records that have been administratively closed to ensure compliance with Veterans Health Administration policy and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2020
The Gulf Coast VA Health Care System Director tracks and monitors the process used to administratively close incomplete electronic health record notes by providers who no longer work at the Gulf Coast VA Health Care System.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures and monitors that protected information contained in the Facility Surgical Workgroup minutes is maintained on a secure intranet site in alignment with Veterans Health Administration policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director confirms that patients’ care whose death occurred within 30 days of a surgical procedure are reviewed and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2020
The Gulf Coast VA Health Care System Director ensures that required staff maintain basic life support and advanced cardiac life support certification as required by Veterans Health Administration policy and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Gulf Coast VA Health Care System Director makes sure that required Gulf Coast Health Care System services submit monthly basic life support and advanced cardiac life support compliance reports to the Critical Care Committee.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director verifies that monthly basic life support and advanced cardiac life support compliance reports are provided to the Executive Committee of the Medical Staff as required by Gulf Coast VA Health Care System policy and monitors for compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes sure that Patient Safety Committee meeting minutes reflect a discussion of patient safety activities as required by Gulf Coast VA Health Care System policy and monitors compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes certain that past and future adverse events are reported to the patient safety manager as defined in Gulf Coast Health Care System policy and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that at least one proactive risk assessment is completed every 18 months for The Joint Commission accredited programs as required by Veterans Health Administration policy and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes certain that an effective process is in place to identify and review cases where an institutional disclosure may be indicated and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Gulf Coast VA Health Care System Director reviews the eight identified events that met criteria for consideration of an institutional disclosure as required by Veterans Health Administration policy and takes action as warranted.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that Administrative Investigation Boards are completed within the 45-calendar day timeframe required by Veterans Health Administration policy and monitors compliance.
Pathology Processing Delays at the Memphis VA Medical Center, Tennessee
|
18-02988-198

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Veterans Integrated Service Network Director ensures that Memphis VA Medical Center leaders assess staffing needs, to include factors impacting the ability to recruit and retain staff, develop plans to improve staffing and assist in hiring to staff Pathology and Laboratory Medicine Service as required by the Clinical Laboratory Improvement Amendment and Veterans Health Administration.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director verifies the development and implementation of a formal process to track surgical pathology specimens sent out of the Memphis VA Medical Center for processing and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures a comprehensive assessment of the Pathology and Laboratory Medicine Service to identify specific root causes of surgical pathology specimen delays and ensure steps are taken to prevent risk of future occurrences.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures that Pathology and Laboratory Medicine Service leaders provide an ongoing, comprehensive Quality Management program that identifies the availability of accurate, reliable, and timely test results, and reports to the ordering providers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/30/2020
The Memphis VA Medical Center Director ensures compliance with required surgical pathology Quality Assurance policies and practices, and that Memphis VA Medical Center leaders monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures that an ongoing process is developed and implemented for Memphis VA Medical Center oversight of Pathology and Laboratory Medicine Service quality data, that includes documentation of the discussion of quality assurance and analysis of the data and the development of action plans as needed.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director verifies that all Pathology and Laboratory Medicine Service employees that perform patient testing have updated competencies and documented training on their assigned duties.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2020
The Memphis VA Medical Center Director ensures that Memphis VA Medical Center leaders understand the importance of the issue brief process and comply with the Deputy Under Secretary for Health and Operations Guidance.
Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida
|
19-07429-195

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The West Palm Beach VA Medical Center Director ensures that mental health multidisciplinary treatment plans are completed in accordance with Veterans Health Administration and The Joint Commission guidelines.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding the Interdisciplinary Safety Inspection Team and its associated functions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding Mental Health Environment of Care Checklist training prior to entry on unit 3C and annually thereafter.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The West Palm Beach VA Medical Center Director ensures that the Employee Education Service staff assigns Mental Health Environment of Care Checklist on-line training modules to employees according to their duties and assignments.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The West Palm Beach VA Medical Center Director ensures that deficiencies identified during the Mental Health Environment of Care Checklist inspections are abated according to VHA guidelines, and that appropriate risk mitigation strategies are implemented as needed.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Veterans Integrated Service Network Director ensures that the appropriate Veterans Integrated Service Network level staff complies with guidelines to review semi-annual reports and follow-up to ensure abatement of deficiencies prior to item closure on the Mental Health Environment of Care Checklist.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Under Secretary for Health takes action to ensure that the Mental Health Environment of Care Checklist Work Group reviews and ranks hazards as submitted through the Patient Safety Assessment Tool, and ensures abatement (or waiver of abatement), as indicated.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that patient safety and law enforcement cameras are installed, tested, and monitored according to West Palm Beach VA Medical Center and Veterans Health Administration guidelines.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that a policy on 15-minute safety rounding expectations be developed, and that all permanent and temporarily-assigned staff performing 15-minute safety rounding on unit 3C receive appropriate training regarding their duties.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director develops a mechanism to confirm staff compliance with 15-minute rounding requirements.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that managers and leaders with mental health, environment of care, and patient safety-related responsibilities are knowledgeable about areas and policies governing the areas under their purview.
Comprehensive Healthcare Inspection of the Central California VA Health Care System Fresno, California
|
19-00006-191

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/3/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2020
The chief of staff ensures that service chiefs initiate and complete focused professional practice evaluations and monitors service chiefs’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that service chiefs include the review of service-specific data for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff ensures service chiefs include review of ongoing professional practice evaluation data in the determination to continue current privileges and monitors the service chiefs’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that the Medical Executive Council meeting minutes consistently reflect the review of focused and ongoing professional practice evaluation results in the decision to recommend continuation of initially granted or ongoing privileges and monitors committee’s compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The associate director ensures that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The associate director makes certain that VA police document response time for panic alarm testing at the locked mental health inpatient unit and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director ensures that electronic access for performing or monitoring controlled substances balance adjustments is limited to appropriate staff and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff ensures that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
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