All Reports

Deficiencies in Discharge Planning for a Mental Health Inpatient Who Transitioned to the Judicial System from a Veterans Integrated Service Network 4 Medical Facility
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18-03576-158

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The Veterans Integrated Service Network Director solicits an ethics consult regarding the patient’s final episode of care and treatment course including the failure to inform the patient or family of impending arrest and lack of family inclusion in decision-making.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director strengthens inpatient mental health unit processes to include the patient, family members, or surrogate in treatment and discharge planning decisions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2021
The Facility Director evaluates the inpatient mental health unit assessment practices of patients’ decision-making capacity and voluntary admission status, and takes actions as appropriate.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director ensures that facility staff identify and document patients’ surrogates accurately.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director ensures that inpatient mental health unit discharge processes include a complete medical and psychiatric diagnostic summary to patients’ receiving mental health providers.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2020
The Facility Director develops inpatient mental health unit discharge processes that include a clinical hand-off communication to patients’ receiving mental health providers.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Facility Director ensures that a mental health treatment coordinator is assigned for patients during all episodes and levels of mental health care.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director ensures that informed consent is obtained from patients or authorized surrogates for release of information as required.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2020
The Facility Director evaluates inpatient mental health unit admission practices and develops processes in compliance with Veterans Health Administration policy regarding voluntary and involuntary admissions.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/26/2019
The Facility Director provides guidance to clinical staff regarding access to consultative resources such as forensic mental health experts, Office of General Counsel, and Ethics Consultation Service.
Review of Mental Health Clinical Pharmacists in Veterans Health Administration Facilities
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18-00037-154

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health ensures facility medical staff bylaws are consistent with Veterans Health Administration policy regarding clinical pharmacist practice as non-independent practitioners.
No. 2
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Under Secretary for Health ensures collaborating agreements, also referenced as collaborative practice agreements, are in place for mental health clinical pharmacists who provide outpatient collaborative medication management.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health ensures that the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews existing Veterans Health Administration guidance and provides assistance in outlining the mental health clinical pharmacist’s responsibilities for communication with the collaborating licensed independent practitioner who has prescribing authority.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The Under Secretary for Health affirms allowable clinical duties within mental health clinical pharmacists’ scopes of practice include comprehensive provisions related to mental health.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2020
The Under Secretary for Health ensures a process is in place for chiefs of mental health service to document review, recommendation, and endorsement of all outpatient mental health clinical pharmacists’ scopes of practice, regardless of whether the clinical pharmacist is aligned with the mental health service line, and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews and provides input into the patient referral process to mental health clinical pharmacists with consideration for ensuring that accurate diagnoses can be reliably identified by and conveyed to the mental health clinical pharmacists.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/5/2022
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director reviews the patient referral process to mental health clinical pharmacists and provides input with consideration for clinical settings or scenarios in which a review of the clinical complexity of the referral by a licensed independent practitioner with prescribing authority would be appropriate, prior to treatment.
No. 8
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 7/25/2019
The Under Secretary for Health ensures the Veterans Health Administration Office of Mental Health and Suicide Prevention Director establishes guidance and provides assistance in outlining when and how mental health clinical pharmacists are to refer patients to a higher level of mental health care.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/8/2020
The Under Secretary for Health initiates a risk assessment of outpatient mental health clinical pharmacists’ practice and establish mitigation plans; and includes the Veterans Health Administration Office of Mental Health and Suicide Prevention Director in the design, implementation, and analysis processes.
Delay in Diagnosis and Subsequent Suicide at a Veterans Integrated Service Network 15 Medical Facility
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19-00022-153

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2021
The Under Secretary for Health ensures that the planning and implementation of the new electronic medical record includes, (a) a fail-safe system that allows communication and tracking of test results to multiple clinical staff members who coordinate patient notification, appropriate follow-up testing and clinical management, and (b) the ability to monitor actions taken by the responsible provider(s).
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director initiates an administrative review of the clinical care the patient received and takes action as appropriate based on the results.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Veterans Integrated Service Network 15 Medical Facility Director ensures that Patient Centered Management Module provider and patient assignments are timely, and data are validated as required by Veterans Health Administration policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/18/2020
The Veterans Integrated Service Network 15 Medical Facility Director issues guidance that establishes a clearly-defined process for the designation of surrogates to include abnormal test results and consults.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The Veterans Integrated Service Network 15 Medical Facility Director confirms that once issued, providers are trained on the process for designation of surrogates and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director reviews current view alert parameters, evaluates providers’ knowledge and management of view alerts, and takes action, as necessary, to ensure and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
The Veterans Integrated Service Network 15 Medical Facility Director evaluates communication among Patient Aligned Care Team members, including the sharing of, the timeliness of, and the response to patient secure messages, and takes action based on the evaluation.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews processes within Primary Care related to patient notification of test results and takes action to ensure test results are communicated to patients as required by Veterans Health Administration policy.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews Veterans Health Administration and the Veterans Integrated Service Network 15 Medical Facility policies concerning disclosure of adverse events to patients and/or their representatives and ensures that staff are aware of discussions and documentation required to comply with these policies.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews the events in the patient’s care and conducts additional actions related to the disclosure of adverse events to the patient’s representative as warranted by Veterans Health Administration and Veterans Integrated Service Network 15 Medical Facility.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/4/2019
The Veterans Integrated Service Network 15 Medical Facility Director reviews quality management practices and ensures compliance with Veterans Health Administration guidance related to root cause analysis when future adverse events are identified and takes action as necessary.
Staffing and Vacancy Reporting under the MISSION Act of 2018
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19-00266-141

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 11/14/2019
Ensure VA vacancy data are reported by occupation as required by Section 505(a)(1)(c) of the Mission Act.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 11/14/2019
Make certain that VA staffing gains and losses data are reported by quarter as required by Section 505(a) part (b) of the MISSION Act.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 6/22/2020
Annotate limitations clearly within the staffing and vacancy data to improve transparency and usability of the data, to include changes from HR Smart data cleansing efforts.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 11/14/2019
Ensure that the staffing and vacancy reporting Web-site maintains historical information on the data elements required by the MISSION Act.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)
Closure Date: 6/22/2020
Update the methodology for collecting and reporting on VA staffing and vacancy data to ensure consistency in future quarters.
Alleged Deficiencies in Out of Operating Room Airway Management Processes at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas
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18-02765-144

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2019
The VA Eastern Kansas Health Care System Director implements documentation training for facility staff, including the Associate Chief of Staff for Education, and monitors compliance with out of operating room airway management documentation for completeness and accuracy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2019
The VA Eastern Kansas Health Care System Director verifies that facility out of operating room airway management policy and out of operating room airway management providers comply with Veterans Health Administration requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management staff are trained as required and monitor compliance, including tracking verification of out of operating room airway management competencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/19/2019
The VA Eastern Kansas Health Care System Director ensures that facility policy and use of Veterans Administration Form 10-0544, Privilege and Competency Verification, is consistent with VHA requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The VA Eastern Kansas Health Care System Director ensures that facility out of operating room airway management workgroups monitor progress toward implementation of Veterans Health Administration Directive 1157(1), Out of Operating Room Airway Management, June 14, 2018, Amended September 19, 2018.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
18-02765-144The VA Eastern Kansas Health Care System Director verifies that facility leaders review the VetPro process and ensures all credentialing and privileging files are complete as required by VHA policy and takes action as necessary based on the findings.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/27/2020
The VA Eastern Kansas Health Care System Director verifies that the Cardiopulmonary Resuscitative Committee analyzes and aggregates data and implements desired changes, as outlined Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation, and monitors compliance.
Alleged Unapproved Acquisition of a Robotic Surgical System for the W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina
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18-03260-102

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/6/2020
The Deputy Under Secretary for Health for Operations and Management directs the Healthcare Technology Management Program Office to clarify High Cost, High Tech approval requirements to Veterans Integrated Service Network 6 officials, including biomedical engineers, logistics staff, equipment specialists, and financial officers, and to the Veterans Health Administration Procurement and Logistics Office.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2020
The Veterans Integrated Service Network 6 network director updates and disseminates VHA requirements to request Assistant Deputy Under Secretary for Health for Administrative Operations approvals for High Cost, High Tech purchases that cost over $1 million, including surgical robots, to the members of the Veterans Integrated Service Network 6 Capital Investment Board and Veterans Integrated Service Network 6 staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2020
The Veterans Integrated Service Network 6 Capital Investment Board meets each fiscal year to ensure that all facility equipment requests more than $1 million are reviewed in a timely manner, including fiscal year-end purchases.
Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center, Chicago, Illinois
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18-04673-138

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The chief of staff ensures utilization management reviewers complete at least 75 percent of all inpatient stay reviews and monitors the reviewers’ 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 required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director ensures the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the Cardiopulmonary Resuscitation Committee’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated timeframes and monitors clinical managers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director makes certain that controlled substances program staff perform one random day’s reconciliation of controlled substances returned to pharmacy from every automated dispensing unit during monthly inspections and monitors the program staff’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 controlled substances inspectors verify documentation for two signatures for any waste of partial doses and monitors controlled substances inspectors’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/4/2020
The facility director confirms that mental health and primary care providers complete military sexual trauma mandatory training requirements no later than 90 days after entering their position 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 ensures clinicians provide and document patient/caregiver education and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
The chief of staff makes certain that program managers implement a process for trackingcervical cancer screening data and monitors program managers’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/17/2021
The chief of staff confirms that providers notify patients of abnormal cervical pathology results within the required timeframe and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director ensures that the urgent care center is discontinued and patient needs and flow are more adequately addressed in the established emergency department and primary care clinic, and monitors compliance.
Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital, Hines, Illinois
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18-04676-142

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2020
The facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief Business Office revenue-utilization review and monitors the committee’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The facility director ensures the Acute and Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The chief of staff makes certain that the Medicine Service Line chief includes required gastroenterology-specific criteria in ongoing professional practice evaluations of gastroenterology practitioners and monitors the Medicine Service Line chief’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The associate director confirms storage rooms meet fire safety requirements by maintaining the required amount of open space between fire sprinkler deflectors and the top of stored items and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The associate director ensures that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The facility director makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2020
The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2020
The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/6/2020
The facility director confirms that the Women Veterans Health Committee includes required core members, designated members consistently attend meetings, and monitors the committee’s compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/16/2019
The chief of staff ensures that program managers implement a process for tracking results notification and follow-up care data for abnormal cervical cancer screenings and monitors program managers’ compliance.
Review of Environment of Care, Infection Control Practices, Provider Availability, and Leadership, VA Loma Linda Healthcare System, California
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18-02405-146

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director ensures implementation of system-wide comprehensive environment of care practices and a safe, sanitary, and high-quality environment consistent with Veterans Health Administration policy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The VA Loma Linda Health Care System Director makes certain that Environmental Management Service managers establish standard operating procedures and consistent processes for staff training.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The VA Loma Linda Health Care System Director implements a standardized process and accountability for validating Environmental Management Service staff competencies.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2020
The VA Loma Linda Health Care System Director verifies compliance with Veterans Health Administration policies for Sterile Processing Services controls.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The VA Loma Linda Health Care System Director complies with Veterans Health Administration policies developed to support Infection Prevention and Control Program issues identified in this report.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director ensures that hot water temperature systems are 124 degrees Fahrenheit or higher to inhibit Legionella growth.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Healthcare System Chief of Staff and Associate Director of Patient Care Services implements a standardized process, consistent with Veterans Health Administration policy, to notify clinical staff involved in direct patient care when routine environmental water testing is positive for Legionella to increase diagnostic awareness.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The VA Loma Linda Health Care System Director continues to recruit and hire for hospitalist vacancies.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director monitors action plans for the Mental Health Strategic Analytics for Improvement and Learning measures.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2020
The VA Loma Linda Health Care System Director completes a review of mental health staffing and continues efforts to recruit and hire for Mental Health Service vacancies.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The Veterans Integrated Service Network 22 Director verifies that the Loma Linda VA Health Care System Director implements action items from previous external Veterans Health Administration site reviews.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director makes certain that senior leaders consistently attend comprehensive environment of care monitoring rounds.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/25/2019
The VA Loma Linda Health Care System Director designates staff members to consistently enter data into the Comprehensive Environment of Care Assessment and Compliance Tool and takes action, as necessary, to complete or address environment of care deficiencies to meet Environmental Program Service goals.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2020
The Veterans Integrated Service Network 22 Director establishes a Veterans Integrated Service Network comprehensive environment of care policy and the VA Loma Linda Health Care System Director implements a facility level policy as required.
VA’s Administration of the Transformation Twenty-One Total Technology Next Generation Contract
|
17-04178-46

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/28/2021
The Technology Acquisition Center associate executive director provide written requirements, in designation memoranda or other written medium, that identify the method and level of detail required for program office contracting officers’ representatives to adequately document their review of contractor deliverables and determination of acceptability.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/28/2021
The Technology Acquisition Center associate executive director develop procedures for Technology Acquisition Center contracting officers to ensure review and acceptability of contractor deliverables is adequately documented in contract files to help prevent improper payments.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 5/14/2020
The Technology Acquisition Center associate executive director develop timeliness requirements for program office contracting officers’ representatives to submit contractor performance assessments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/30/2020
The Technology Acquisition Center associate executive director develop written follow-up procedures that standardize the actions Technology Acquisition Center contracting officers should take when program office contracting officers’ representatives do not comply with the developed timeliness requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/30/2020
The Technology Acquisition Center associate executive director implement procedures to monitor Technology Acquisition Center contracting officers’ actions through compliance reviews to ensure they adhere to written procedures.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/30/2020
The Technology Acquisition Center associate executive director assess the risk introduced by removing the requirement to review Past Performance Information Retrieval System records and implements a control that mitigates this risk.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 12/28/2021
The Technology Acquisition Center associate executive director enhance written procedures by providing Technology Acquisition Center contracting officers with standards that define higher-risk financial stability risk scores and subsequent actions that should be taken when these scores are identified.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,500,000.00
Alleged Complications Associated with Phototherapy at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi
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17-03399-140

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The Gulf Coast Veterans Health Care System Director confirms current dermatology clinic nursing practice requirements related to ensuring informed consent prior to initiating phototherapy are followed and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2020
The Gulf Coast Veterans Health Care System Director ensures dermatology clinic registered nurse training and competencies are completed as required and tracked for compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Gulf Coast Veterans Health Care System Director reviews facility policy to ensure guidance clearly delineates environmental actions to be taken following identification of bed bugs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/21/2019
The Gulf Coast Veterans Health Care System Director ensures that all Gulf Coast Veterans Health Care System staff are trained on the policy addressing environmental actions to be taken following identification of bed bugs and track compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Gulf Coast Veterans Health Care System Director ensures that the Patient Safety Manager completes all actions identified in the subject adverse event review.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/14/2019
The Veterans Integrated Service Network 16 Director reviews the Gulf Coast Veterans Health Care System policy related to the confidentiality of fact-finding reviews to evaluate if the initiation of such reviews, including the one conducted in relation to this patient, is consistent with the purpose of maintaining the confidentiality of quality management activities, and takes action as necessary.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The Veterans Integrated Service Network 16 Director reviews and evaluates the proposed and actual disciplinary actions taken by Gulf Coast Veterans Health Care System managers related to the events of the day in question, and takes action as appropriate.
Inadequate Oversight of Contracted Disability Exam Cancellations
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18-04266-115

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/17/2021
The Under Secretary for Benefits improve the exam management systems to ensure visibility of the information needed to conduct adequate oversight of contracted disability exam cancellations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2020
The Under Secretary for Benefits ensure staffing is sufficient so that the Medical Disability Examination Program can perform adequate oversight of contracted disability exam cancellations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/10/2019
The Under Secretary for Benefits take steps to ensure that contracting officer’s representatives with oversight responsibilities for the Medical Disability Examination contracts achieve the VA-required certification level.
Exempt Veterans Charged VA Home Loan Funding Fees
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18-03250-130

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2020
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees during the period from January 1, 2012, through December 31, 2017, and issue refunds.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2020
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees prior to January 1, 2012, and issue refunds.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/14/2019
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to mitigate the lack of real-time funding fee exemption status updates through system enhancements or procedural changes that minimize inappropriate funding fee charges.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/23/2020
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to conduct periodic reviews to identify exempt veterans charged funding fees from January 1, 2018, forward, and issue refunds in a timely manner.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/14/2019
Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to consistently obtain documentation and verify lenders apply funding fee refunds to veterans’ loan balances in a timely manner.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 352,600,000.00
VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2018
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18-05864-127

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/30/2021
The Under Secretary for Health implement steps to achieve stated reduction targets for the following programs and activities: Communications, Utilities, and Other Rent; Medical Care Contracts and Agreements; and State Home Per Diem.
Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan
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18-04669-125

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and then monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2020
The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The chief of staff ensures that clinical managers clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors the clinical managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The chief of staff ensures providers complete initial evaluations within the required timeframe for all new patients referred for mental health services for military sexual trauma and monitors the providers’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/10/2020
The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the potential interactions and side effects of newly prescribed medications and monitors the clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors the clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The facility director makes certain that the urgent care center is staffed with registered nurses in accordance with VHA policy at all times of operation and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2020
The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
Decision Ready Claims Program Hindered by Ineffective Planning
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18-05130-105

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 5/21/2019
The Under Secretary for Benefits works with the VA Secretary and Chief Financial Officer to take steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for funds already obligated and expended for medical examinations under the Decision Ready Claims program.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 10,572,000.00
Deferrals in the Veterans Benefits Management System
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18-00215-83

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits implement plans to enhance quality assurance by conducting periodic national oversight of deferrals and ensuring local oversight specifically addresses all aspects of the accuracy of deferrals created in the Veterans Benefits Management System.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/15/2019
The Under Secretary for Benefits establish internal controls documenting Rating Veterans Service Representatives are informed of their mitigated deferrals and corrective action is taken.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/19/2021
The Under Secretary for Benefits update guidance to clarify why certain reason selections should be made for deferrals, provide training on this guidance, and monitor the effectiveness of the training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2021
The Under Secretary for Benefits establish plans to modify the Veterans Benefits Management System to allow sufficient space for inputting deferral instructions and require claims processors to input references when creating deferrals.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 1,100,000.00
Inpatient Mental Health Clinical Operations Concerns at the Phoenix VA Health Care System, Arizona
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17-02629-119

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Phoenix VA Health Care System Director verifies that clinicians document clinical justification for the continued use of restraints and debriefing sessions according to Veterans Health Administration and Phoenix VA Health Care System policy requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director makes certain that the Phoenix VA Health Care Patient Safety Observer policy is followed, and compliance is monitored.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System, Director ensures that inpatient mental health unit nurse staffing methodology is conducted as required by Nurse Staffing Methodology for Veterans Health Administration Nursing Personnel Directive.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2020
The Phoenix VA Health Care System, Director confirms that mental health staff receive mandated training at required intervals including training for patients with dementia as appropriate, and compliance is monitored.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director verifies that the inpatient mental health unit is cleaned on a regular basis and compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/21/2020
The Phoenix VA Health Care System Director ensures that the environment on the inpatient mental health unit is a home-like therapeutic setting as required by Veterans Health Administration Inpatient Mental Health Services Handbook.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2019
The Phoenix VA Health Care System Director ensures that Phoenix VA Health Care System staff enter complaints into the Patient Advocate Tracking System consistent with current Veterans Health Administration Patient Advocacy Program and facility policies and compliance is monitored.
Orthopedic Surgery Department and Other Concerns at the Carl T. Hayden VAMC, Phoenix, Arizona
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18-02493-122

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director conducts comprehensive reviews of all aspects of decision-making and care provided to Patient Red and Patient Blue, and takes action, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director considers conducting an institutional disclosure in Patient Red’s case, and takes action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director continues efforts to assess and improve inefficiencies, including on-call surgeon accountability issues, within the Orthopedic Surgery Department.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Carl T. Hayden VA Medical Center Director takes appropriate action relative to the letter of expectation issued to the Chief of Orthopedic Surgery Department.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director addresses inter-departmental communication, collaboration, and problem-solving challenges as discussed in this report.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director follows up on consultative recommendations made by the anesthesia and operating room site visit team.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director evaluates the adequacy of Sterile Processing Services space and the loaner instrument policy, and takes action as appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director assesses the feasibility of implementing an electronic instrument tracking system within Sterile Processing Services, and takes actions as appropriate.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Carl T. Hayden VA Medical Center Director revises the orthopedic surgery core privileges description to accurately reflect procedures performed at the Carl T. Hayden VA Medical Center.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2020
The Carl T. Hayden VA Medical Center Director ensures appropriate data collection, analysis, and reporting for orthopedic providers’ ongoing professional practice evaluations.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/21/2019
The Carl T. Hayden VA Medical Center Director develops a physician assistant utilization policy as required by Veterans Health Administration.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The Carl T. Hayden VA Medical Center Director updates physician assistant scopes of practice to fully reflect the activities and listing of surgical first assist responsibilities for individual orthopedic physician assistants.
Staffing, Quality of Care, Supplies, and Care Coordination Concerns at the VA Loma Linda Healthcare System, California
|
17-02186-114

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System Director defines goals, implements measures, and monitors outcomes to improve the flow of patients throughout the hospital, including the Emergency Department, inpatient medical and surgical units, mental health units, and the Community Living Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director conducts a review to evaluate the accuracy of data entered in Emergency Department Integration Software and takes action to ensure that the data collection tool may be used for operational improvement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System Director ensures that patients admitted to a unit where there is no bed available receive the same level of care that is provided in the unit to which they are assigned.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director ensures that bed closures are reported to the Veterans Integrated Service Network as required by VA Loma Linda Healthcare System policy.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/29/2020
The VA Loma Linda Healthcare System Director evaluates the care of patients with sepsis in the Emergency Department, identifies opportunities for improvement, and takes actions to improve care.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2020
The VA Loma Linda Healthcare System Director evaluates the response time of psychiatrists consulted for the care of mental health patients in the Emergency Department and takes action if required.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Loma Linda Healthcare System Director conducts an evaluation of Patient C’s 2016 coordination of care, discharge planning, and transfer of care, including but not limited to, conferring with the Director of the Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky, and takes action as necessary.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/15/2020
The VA Loma Linda Healthcare System evaluates, develops, and implements processes for veterans who have anticipated or unexpected medical needs coordinated by their preferred medical facility and an alternate medical facility.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The VA Loma Linda Healthcare System Director evaluates and ensures that root cause analyses are completed in accordance with Veterans Health Administration directives.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The VA Loma Linda Healthcare System Director reviews the care of the two fall patients with injuries discussed in this report, adheres to Veterans Health Administration policies, and takes action as appropriate.
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