Date Issued
|
Report Number
20-02562-188
|
Topics: Financial Management
All Reports
Date Issued
|
Report Number
18-01622-207
|
Topics: Appointment Scheduling and Wait Times
● Community Care
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/20/2023
The Atlanta VA Health Care System Director reviews the process for non-VA community care consult performance measurements, evaluates compliance with Veterans Health Administration policy, and implements an action plan as needed.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/20/2023
The Atlanta VA Health Care System Director ensures managers review the backlog of open non-VA community care consults and implements an action plan as needed.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/16/2021
The Atlanta VA Health Care System Director verifies that managers develop a process to analyze and confirm non-VA community care staff compliance with daily monitoring according to Veterans Health Administration policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The Atlanta VA Health Care System Director evaluates the process for the hiring, training, and supervision of non-VA community care staff, and implements an action plan as needed.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/12/2021
The Atlanta VA Health Care System Director ensures that managers review the patient cases referred to the Atlanta VA Health Care System by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Atlanta VA Health Care System Director makes certain that managers develop a policy to identify non-VA Community Care consults that are administratively closed but do not have relevant medical documentation, and implements an action plan as needed to be in alignment with Veterans Health Administration policy.
Date Issued
|
Report Number
20-03076-217
|
Topics: COVID-19
Date Issued
|
Report Number
20-00206-180
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/27/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures action items are implemented when problems or opportunities for improvement are identified and documented in Executive Leadership Council minutes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
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. 3
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
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. 6
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review forms within seven calendar days of the professional’s departure from the medical center.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Associate Director for Operations evaluates and determines any additional reasons for noncompliance and ensures that medical center managers repair or remove damaged wheelchairs from service.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Associate Director for Operations evaluates and determines any additional reasons for noncompliance and ensures that staff secure protected health information within laboratory transport containers.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians complete pain screening for all patients prior to initiating long-term opioid therapy.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a 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. 11
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients who are initiated on long-term opioid therapy.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
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. 15
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
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 effectiveness of intervention(s) provided.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 8/31/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the medical center’s Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that Suicide Prevention Safety Plans include all required elements.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures clinical and non-clinical staff receive annual suicide prevention refresher training.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners enter life-sustaining treatment notes that include all required elements in patients’ electronic health records as required.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that community-based outpatient clinics have a designated Women’s Health Patient Aligned Care Team.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 5/27/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures processes and procedures are in place for gynecological care coverage 24 hours a day/7 days per week.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has designated women’s health primary care providers.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the availability of timely access to emergency contraceptives at the Evansville VA Clinic.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required core members are assigned and consistently attend Women Veterans Committee meetings.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.
No. 26
to Veterans Health Administration (VHA)
Closure Date: 4/15/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all equipment is entered into the CensiTrac® Instrument Tracking System.
No. 27
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief consistently performs an annual risk analysis and reports the analysis to the VISN Sterile Processing Services Management Board.
No. 28
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is reprocessed.
No. 29
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services managers properly complete competency assessments for staff reprocessing reusable medical equipment.
Date Issued
|
Report Number
19-06451-165
|
Topics: Healthcare Infrastructure
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/27/2021
The Under Secretary for Health establish a formal process for requesting and obtaining the approval of the VA Secretary for research studies that use canine subjects to comply with applicable restrictions on the use of appropriated funds.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/30/2022
The Under Secretary for Health develop and implement processes for documenting and maintaining records of the VA Secretary’s approval of canine research studies, including the study at the Richmond VAMC that was not included in the Secretary’s August 30, 2019, approval document.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/27/2021
The Under Secretary for Health establish controls for ensuring appropriate funds are not spent for canine research studies before obtaining the VA Secretary’s approval.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/7/2022
The Under Secretary for Health review local accounting records and cost allocations to determine the total amount of FY 2018 and 2019 funds spent on canine research before the VA Secretary approved the studies and report this information to the House and Senate appropriations committees.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/27/2021
The Under Secretary for Health work with the VA Secretary and the chief financial officer to take the steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for the funds obligated and expended for research studies involving canine subjects.
Date Issued
|
Report Number
19-09410-203
|
Topics: VA Police
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and makes changes to ensure staff and supervisors are aware of and follow reporting requirements arising from off-facility patient disruptive behavior incidents.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and implements changes to address traumatic injury needs of staff who may be experiencing an emotional or mental health injury as a result of a work related incident.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/26/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and implements changes to ensure timely notification of threats to targeted staff.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies for the placement of behavioral flags and makes changes to ensure patient record flags are placed to address immediate safety issues.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The VA Southern Nevada Healthcare System Director ensures that VA Southern Nevada Healthcare System VA police fulfill their obligation to fully participate with the Disruptive Behavior Committee, including the triage of Disruptive Behavior Response System entries, and confirms that potential criminal or safety issues are timely addressed.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/14/2021
The VA Southern Nevada Healthcare System Director reviews the VA Southern Nevada Healthcare System Housing and Urban Development-Veterans Affairs Supporting Housing staffing levels and practices to ensure staffing and training safely meet the demands of the program.
Date Issued
|
Report Number
19-09416-186
|
Topics: Suicide Prevention
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define and document expectations for focused professional practice evaluations in provider profiles prior to assessment.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that first- or second-line supervisors complete provider exit review forms within seven calendar days of a provider’s departure from the medical center.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavior risk assessment that includes a history of substance abuse, psychological factors, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for concurrent opioid and benzodiazepine medication therapy.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff determines the reason for noncompliance and make certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff determines the reasons for noncompliance and makes certain that healthcare providers obtain and document informed consent consistently for patients prior to initiating long-term opioid therapy.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
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. 9
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up of patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Interim Medical Center Director determines the reasons for noncompliance and ensures that the Pain Management Sub-Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 6/4/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians conduct four follow-up appointments, either face-to-face or telephonic with documented consent, within the required time frame.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain staff receive annual suicide prevention refresher training.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/28/2021
The Interim 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 or arrangements for leave coverage when CBOCs have only one designated provider.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 11/22/2021
The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee is comprised of the required core members.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 3/5/2021
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
Date Issued
|
Report Number
19-06864-183
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
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. 2
to Veterans Health Administration (VHA)
Closure Date: 11/19/2020
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director determines reasons for noncompliance and ensures that root cause analyses include all required review elements.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
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: 12/10/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete provider exit review forms within seven calendar days of licensed health care professionals’ departure from the medical center.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavior risk assessment on all patients prior to initiating long-term opioid therapy.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients when initiating long-term opioid therapy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff determines reasons for noncompliance and ensures healthcare providers follow up with patients within the required timeframe after initiating long-term opioid therapy.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that staff receive annual suicide prevention refresher training.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/22/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that practitioners complete and document all required elements of life-sustaining treatment plan progress notes.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and certifies that a multidisciplinary committee is established to review proposed life-sustaining treatment plans.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Advisory Committee For Women Veterans includes required core members.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 9/3/2021
The Associate Director for Patient Service evaluates and determines any additional reasons for noncompliance and makes certain that Chief of Sterile Processing Services completes valid competency assessments for staff reprocessing reusable medical equipment.
Date Issued
|
Report Number
19-00230-190
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/9/2021
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction requires in any award made on a noncompetitive basis that the contracting officer obtain a written disclosure and certification by the program sponsor, contracting officer’s representative, and other staff involved in the procurement as appropriate, disclosing any personal or professional relationship between such staff and vendor personnel.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/2/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the conduct and performance of the contracting officer, the Agency Competition Advocate, and the two higher-level supervisors involved in this procurement.
No. 3
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/30/2020
The Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness determines what administrative action should be taken, if any, with respect to the conduct and performance of the HR&A Program Director and the Contracting Officer’s Representative.
No. 4
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/2/2020
VA’s Senior Procurement Executive determines what action, if any, should be taken with respect to the contracting officer’s warrant consistent with the authority granted by VA Acquisition Regulation § 801.690-6.
No. 5
to General Counsel (OGC)
Closure Date: 12/14/2020
The Acting General Counsel reviews the circumstances of this procurement and uses that information to help determine whether it is appropriate for counsel to sign attestations on Justification and Approval forms, and issues policy guidance in accordance with that determination.
No. 6
to Acquisitions, Logistics, and Construction (OALC),General Counsel (OGC)
Closure Date: 12/2/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction, in consultation with the Office of General Counsel, reviews the Small Business contract to determine what actions should be taken, if any, to recover funds or otherwise address the waste of VA funds.
No. 7
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/2/2020
The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the contracting officers’ acceptance of substitute performance that provided no value to VA.
No. 8
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 11/30/2020
The Assistant Secretary of Human Resources and Administration (HR&A) / Operations, Security, and Preparedness determines what administrative action to take, if any, with respect to the Contracting Officer Representative’s failure to perform diligence sufficient to identify the cloud-computing issues associated with this procurement.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 4,999,500.00
Date Issued
|
Report Number
19-00017-191
|
Topics: Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/7/2021
The Under Secretary for Health completes a specialty care needs assessment for highly rural community-based outpatient clinics to include internet bandwidth and telehealth equipment and develops options for the delivery of safe patient care.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Under Secretary for Health ensures that the Veterans Health Administration Site Tracking system validation process is completed by each Veterans Integrated Service Network as required and monitors for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/11/2021
The Under Secretary for Health ensures that facilities and Veterans Integrated Service Networks maintain accurate and current information on websites as required and monitors for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/13/2021
The Under Secretary for Health completes an assessment to determine whether highly rural community-based outpatient clinics that are located in a non-VA community hospital or health care center are fully utilizing the resources available at the non-VA facilities and takes action as indicated.
Date Issued
|
Report Number
20-00082-189
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff determines the reasons for noncompliance and ensures all staff complete annual suicide prevention refresher training.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/20/2021
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. 3
to Veterans Health Administration (VHA)
Closure Date: 5/20/2021
The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are included in the Women Veterans Health Committee charter and attend the quarterly meetings.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/9/2020
The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Date Issued
|
Report Number
19-09377-192
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/25/2020
The Under Secretary for Health initiates review of the Veterans Health Administration’s credentialing policy to determine the need for requirement clarification related to prior employment history to include applicant listing of locum tenens contracting companies.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The W. G. (Bill) Hefner VA Medical Center Director ensures credentialing and privileging staff verify applicants’ information within the required timeframe outlined by Veterans Health Administration policy and monitors for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/28/2021
The W. G. (Bill) Hefner VA Medical Center Director ensures annual proficiency reports are completed and maintained consistent with Veterans Health Administration requirements and monitors for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The W. G. (Bill) Hefner VA Medical Center Director ensures all available performance and competency information is provided to the Professional Standards Board for consideration during provider probationary and reprivileging reviews and monitors for compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/17/2020
The W. G. (Bill) Hefner VA Medical Center Director ensures that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
Date Issued
|
Report Number
19-07543-178
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Veterans Integrated Service Network Director conducts a comprehensive review of the patient’s care including collaboration among Patient Aligned Care Team members and takes action as indicated.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/19/2021
The Tennessee Valley Healthcare System Director ensures facility staff are aware of and follow Veterans Health Administration Directive 1088, Communicating Test Results to Providers and Patients, specifically the requirement for the ordering clinician to communicate all test results to patients.
Date Issued
|
Report Number
19-09436-185
|
Topics: Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/18/2021
The VA Pittsburgh Healthcare System Director considers developing a facility policy for bariatric surgery to include preoperative medical and mental health evaluations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The VA Pittsburgh Healthcare System Director ensures that bariatric patients receive all preoperative medical and mental health evaluations and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The VA Pittsburgh Healthcare System Director reviews the documentation error noted in this report and takes action as appropriate.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/7/2021
The VA Pittsburgh Healthcare System Director provides education to staff on how to correct documentation errors and the requirement to follow facility policy.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/25/2021
The VA Pittsburgh Healthcare System Director ensures interdisciplinary discussions about preoperative bariatric patients are documented in the electronic health record and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/7/2021
The VA Pittsburgh Healthcare System Director considers a programmatic review of the Bariatric Surgery Program to ensure patients receive a comprehensive preoperative evaluation and postoperative follow-up care.
Date Issued
|
Report Number
20-00067-172
|
Topics: Medical Staff Privileging Credentialing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff determines the reason(s) for noncompliance and ensures that ongoing professional practice evaluations include service-specific criteria.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Executive Committee minutes consistently reflect the review of professional practice evaluation results.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing for patients prior to initiating or continuing long-term opioid therapy and periodically thereafter.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/23/2021
The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within the required time frame after initiating long-term opioid therapy.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/1/2020
The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the VISN Sterile Processing Services Management Board.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that include at least two methods of verification for reprocessing reusable medical equipment.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/4/2020
The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Date Issued
|
Report Number
19-07281-105
|
Topics: Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/13/2021
The OIG recommended the Under Secretary for Health conduct a formal analysis of VHA’s Office of Community Care prescription drug programs to determine what steps VA would need to take to require drug manufacturers to provide Big 4 prices for covered prescription drugs purchased for CHAMPVA and any other VA Community Care programs that use a retail pharmacy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/13/2021
The OIG recommended the Under Secretary for Health collaborate with the Office of Regulatory and Administrative Affairs and, if determined appropriate, pursue any proposed statutory or other changes needed to provide VA with the appropriate legal authority to purchase all prescription drugs through retail pharmacies at the Big 4 prices.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 345,100,000.00
Date Issued
|
Report Number
20-00010-151
Date Issued
|
Report Number
20-00184-153
Date Issued
|
Report Number
18-02929-157
Date Issued
|
Report Number
18-02164-156