All Reports

Intraoperative Radiofrequency Ablation and Other Surgical Service Concerns, Samuel S. Stratton VA Medical Center, Albany, New York
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17-01770-188

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Veterans Integrated Service Network Director ensures that the Facility’s credentialing and privileging program is reviewed for integration of key functions of quality oversight, including the use of quality data for Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation processes and surgical Peer Review program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures that the Facility Peer Review program meets all Veterans Health Administration requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2019
The Facility Director ensures that Surgery Service’s professional practice evaluations include performance data to support provider privileges and contain accurate data.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2019
The Facility Director ensures that a process is developed and implemented to document, report, and track patient cases discussed in the Liver Tumor Board and that meeting minutes are completed and forwarded to oversight groups.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2019
The Facility Director ensures that a process is implemented to track, monitor, and report intraoperative radiofrequency ablation outcomes to Facility and Quality Management leaders.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Facility Director ensures that the Office of General Counsel is consulted on the three patients with missed or partially missed tumors after intraoperative radiofrequency ablation to determine if institutional disclosure might be appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures that the five additional intraoperative radiofrequency ablation patients the Office of Inspector General referred to the Facility, and any other patients who had intraoperative radiofrequency ablation done by Surgeon A, are reviewed by clinicians with qualifications to assess the outcome of these procedures and actions taken as appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures an external review of intraoperative radiofrequency ablation processes is obtained to identify possible causes of missed tumors and methods to improve practice and outcomes.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
The Facility Director ensures that Human Resources and the Office of General Counsel are consulted to determine the appropriate actions, if any, including consideration for ethics review, for staff who were not forthcoming with patients on outcomes of intraoperative radiofrequency ablation.
Comprehensive Healthcare Inspection Program Review of the Bay Pines VA Healthcare System, Florida
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17-01857-264

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The Associate Director ensures that floors in patient care areas are clean and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The Facility Director ensures that the Alternate Controlled Substances Coordinator’s position description or functional statement includes the Control Substance Coordinator’s duties and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/29/2019
The Chief of Staff ensures that the Geriatric Evaluation Social Worker performs the required comprehensive psychosocial assessment and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
The Associate Director for Patient Care Services ensures that all staff involved in inserting and managing central lines receive the required central line-associated bloodstream infection prevention training and monitors compliance.
Use of Not Otherwise Classified Codes for Prosthetic Limb Components
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16-01913-223

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should review the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (August 2011, March 2013, and August 2013), coordinate with appropriate officials to determine which Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes are appropriate to classify these items for reimbursement, and issue revised guidance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2019
The Executive in Charge, Veterans Health Administration, should coordinate with appropriate officials to establish a formal oversight and reporting structure that defines the roles and the responsibilities of the Prosthetic and Sensory Aids Service Orthotic and Prosthetic L Code Committee, as well as who has the authority to approve recommendations for the use of the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes to classify specific prosthetic components for reimbursement.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should develop and implement effective processes and procedures to monitor the use of Not Otherwise Classified codes and communicate these procedures to the Veterans Integrated Service Networks to ensure compliance with Veterans Health Administration Directive 1045, Healthcare Common Procedure Coding System (HCPCS) List for Prosthetic Limb and/or Custom Orthotic Device Prescription (December 30, 2013) and the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II Coding Procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/30/2019
The Executive in Charge, Veterans Health Administration, should coordinate with the appropriate officials to develop and implement processes and procedures to ensure any pricing guidance with regard to the pricing of prosthetic items classified using a Not Otherwise Classified code is developed and concurred with by VA Office of General Counsel and Veterans Health Administration’s Procurement and Logistics Office prior to issuance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The Executive in Charge, Veterans Health Administration, should issue corrected guidance to replace the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (March 2013 and August 2013) and the prosthetic limb contract template issued in August 2014, by coordinating with appropriate officials to develop and implement pricing guidance to ensure VA pays a fair and reasonable price for items classified using a Not Otherwise Classified code.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 21,300,000.00
Comprehensive Healthcare Inspection Program Review of the VA St. Louis Health Care System, Missouri
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18-00612-260

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Chief of Staff ensures that clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/23/2018
The Facility Director ensures that the duties of the Alternate Controlled Substances Coordinator are included in the employee position description or functional statement and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Facility Director ensures that Controlled Substances Inspectors are appointed in writing prior to performing inspector duties and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/4/2019
The Facility Director ensures that controlled substances inspections are completed monthly in all clinical areas and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/1/2019
The Chief of Staff ensures that ordering providers are notified of all mammography results and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina
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18-00600-259

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Associate Director ensures that Facility managers maintain clean floors in patient care areas and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Associate Director ensures that Facility managers ensure that damaged equipment in patient care areas is repaired or removed from service and that Facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2019
The Chief of Staff ensures that mammogram reports are scanned into Veterans Health Information Systems and Technology Architecture Imaging and are viewable by all members of the healthcare team and that Facility managers monitor compliance.
Comprehensive Healthcare Inspection Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri
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18-01011-253

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures the emergency power supply system inspections are performed weekly and monitors compliance.
Processing Inaccuracies Involving Veterans' Intent to File Submissions for Benefits
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17-04919-210

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/18/2019
The OIG recommended the Under Secretary for Benefits take steps to prioritize the modernization of functionality within the Veterans Benefits Management System to assist rating personnel with assigning correct effective dates related to intent to file.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2019
The OIG recommended the Under Secretary for Benefits implement a plan to conduct a special review of claims with intent to file submissions from March 24, 2015, through September 30, 2017, during which payment changes occurred, to determine whether rating personnel assigned correct effective dates when awarding compensation benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 72,500,000.00
Denied Posttraumatic Stress Disorder Claims Related to Military Sexual Trauma
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17-05248-241

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2021
The Under Secretary for Benefits reviews all denied military sexual trauma related claims since the beginning of FY 2017, determines whether all required procedures were followed, takes corrective action based on the results of the review, renders a new decision as appropriate, and reports the results back to the Office of Inspector General.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/2/2019
The Under Secretary for Benefits focuses processing of military sexual trauma related claims to a specialized group of Veterans Service Representatives and Rating Veterans Service Representatives.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/8/2020
The Under Secretary for Benefits requires an additional level of review for all denied military sexual trauma related claims and holds the second level reviewers accountable for accuracy.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2021
The Under Secretary for Benefits conducts special focused quality improvement reviews of denied military sexual trauma related claims and takes corrective action as needed.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/26/2021
The Under Secretary for Benefits updates the current training for processing military sexual trauma related claims, monitors the effectiveness of the training, and takes additional actions as necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/8/2019
The Under Secretary for Benefits updates the development checklist for military sexual trauma related claims to include specific steps claims processors must take in evaluating such claims in accordance with applicable regulations, and requires claims processors to certify that they completed all required development action for each military sexual trauma-related claim.
Comprehensive Healthcare Inspection Program Review of the Erie VA Medical Center, Pennsylvania
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18-00618-261

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2019
The Chief of Staff ensures that the peer reviewer identifies one or more of the Eleven Aspects for Review of Care in the completion of peer reviews and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Chief of Staff ensures that the Ongoing Professional Practice Evaluation process includes the development and utilization of service- and practitioner-specific data and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Associate Director of Patient Care Services ensures that staff follow medication administration, storage, and disposal policies and monitors compliance.
Program of Comprehensive Assistance for Family Caregivers: Management Improvements Needed
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17-04003-222

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/11/2019
The Executive in Charge, Veterans Health Administration, will establish a governance environment for the Program of Comprehensive Assistance for Family Caregivers to ensure medical facilities process veteran applications within the required 45-day timeliness standard, consistently monitor veterans and their caregivers, adequately document the results and changes in veterans’ health status, and adjust the level of support provided or discharge veterans and their caregivers, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The Executive in Charge, Veterans Health Administration, will take steps to ensure caregiver support coordinators are properly applying eligibility criteria with processes, such as pre- or post-approval reviews, to ensure the accuracy of all veteran eligibility determinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/1/2019
The Executive in Charge, Veterans Health Administration, will update Directive 1152, Caregiver Support Program, to include a well-defined process for documenting changes in veterans’ health conditions during monitoring sessions to determine if those changes warrant a reassessment of the need for care or the level of care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2020
The Executive in Charge, Veterans Health Administration, will establish assessment guidelines that caregiver support coordinators should follow when a veteran’s need for care changes.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2019
The Executive in Charge, Veterans Health Administration, will make sure that Veterans Integrated Service Network directors designate program leads at the network level with responsibility for Program of Comprehensive Assistance for Family Caregivers oversight.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/3/2019
The Executive in Charge, Veterans Health Administration, will assess the extent to which current staffing levels at medical facilities are adequate to implement the Program of Comprehensive Assistance for Family Caregivers, as intended.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 41,572,914.00
Postoperative Care Concerns for a Vascular Surgical Patient at the Martinsburg VA Medical Center, West Virginia
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17-05381-258

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2019
The Martinsburg VA Medical Center Director evaluates the coordination of care processes at the Petersburg Community Based Outpatient Clinic and takes action as necessary based on the findings.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/8/2019
The Martinsburg VA Medical Center Director ensures the development and implementation of a policy or standard operating procedure for the management of health emergencies at the Petersburg Community Based Outpatient Clinic, and Petersburg Community Based Outpatient Clinic staff receive training on the policy or standard operating procedure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/20/2019
The Martinsburg VA Medical Center Director evaluates the Petersburg Community Based Outpatient Clinic Patient Aligned Care Team patient health record documentation for accurate and clinically-relevant statements and takes action as necessary based on the findings.
Review of Environment of Care Conditions at Mississippi VA-Contracted Clinics
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18-04633-254

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2019
The Facility Director requires a team of subject matter experts to complete comprehensive reviews of the community based outpatient clinics’ compliance with environment of care and other contract requirements, and initiate corrective action plans, as needed
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/2/2019
The Facility Director ensures that responsible managers and team members provide consistent oversight of community based outpatient clinics operations in accordance with contract requirements.
Comprehensive Healthcare Inspection Program Review of the Dayton VA Medical Center, Ohio
|
18-00619-242

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Chief of Staff ensures that the assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Chief of Staff ensures that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Chief of Staff ensures that the interdisciplinary group review UM data on an ongoing basis and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Chief of Staff ensures that Service Chiefs complete all required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/22/2019
The Associate Director ensures environment of care rounds are conducted in all areas of the Facility at the required frequency and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Associate Director ensures that Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
The Associate Director ensures all medical equipment is identified as safe for patient use and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2019
The Chief of Staff ensures that geriatric evaluation performance improvement activities are conducted, documented, and reviewed by an appropriate leadership board and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/12/2020
The Chief of Staff ensures providers perform geriatric medical evaluations and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Chief of Staff ensures that clinicians accurately identify and implement geriatric evaluation plan of care interventions and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Ann Arbor Healthcare System, Michigan
|
18-00621-245

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/25/2019
The Chief of Staff ensures Facility managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director and Assistant Director ensure required team members participate on Environment of Care rounds and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Beckley VA Medical Center, West Virginia
|
17-05401-240

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Chief of Staff ensures that service line managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Chief of Staff ensures that service line managers collect Ongoing Professional Practice Evaluation data utilizing assessments by providers with similar training and privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Associate Director ensures environment of care rounds are conducted at the required frequency and documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2019
The Associate Director ensures required team members participate on environment of care rounds and that attendance is recorded in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2018
The Facility Director ensures that deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/18/2019
The Facility Director ensures that the controlled substances inspectors consistently perform controlled substances order verification as required and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/23/2019
The Chief of Staff ensures that mammogram results are electronically linked to the radiology orders and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/23/2019
The Associate Director for Patient Care Services ensures that nursing staff involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Chillicothe VA Medical Center, Ohio
|
18-01012-228

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Chief of Staff ensures practitioners’ Focused Professional Practice Evaluations include clearly delineated timeframes and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Tomah VA Medical Center, Wisconsin
|
17-05400-246

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2018
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that reconciliation of controlled substance returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Misuse of Time and Resources within the Veterans Engineering Resource Center in Indianapolis, Indiana
|
17-04156-234

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 1.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 2.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2022
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 3.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against other OSI VERC employees identified by the OIG for misusing government time and resources associated with this endeavor.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2019
The Principal Deputy Under Secretary assesses the adequacy of oversight and training for OSI VERC employees regarding the appropriate use of VA time and resources and addresses any deficiencies.
Review of Two Mental Health Patients Who Died by Suicide, William S. Middleton Memorial Veterans Hospital Madison, Wisconsin
|
17-02643-239

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Facility Director expands the Facility’s Root Cause Analysis of Patient 1’s death to include interviews of all key staff by individuals who are not their supervisors; and if additional deficiencies are identified, ensures that Facility managers complete an action plan and monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Veterans Integrated Service Network Director ensures that the Facility Director consult with the Office of Chief Counsel regarding Patient 1 and Patient 2 whether an institutional disclosure is appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Veterans Integrated Service Network Director ensures an ethics review is completed regarding Patient 1’s participation in the research study and provision of guidance on the voluntary participation of patients under court treatment mandates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Facility Director strengthens processes to ensure that timely notification to county monitoring agencies occurs in cases of court Settlement Agreement violations.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Facility Director strengthens processes to ensure that Facility staff speak directly with and notify the county monitoring agency staff before an inpatient with a court Settlement Agreement is discharged.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2018
The Facility Director revises the mental health inpatient unit policy to include family notification with patient consent in discharge planning and ensures that Facility policy is consistent with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director strengthens processes to ensure that mental health clinical assessments are complete and comprehensive to include a symptom inventory and severity assessment, and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director strengthens processes to ensure that prescribers are prescribing psychiatric medications safely including adherence to the black box warnings, and that managers complete electronic health record reviews to monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/8/2019
The Facility Director ensures the development of a methodology for the assignment of psychiatrists as prescribers for patients with complex mental health care needs, including patients flagged as high-risk for suicide.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director strengthens the Ongoing Professional Practice Evaluation process to ensure that psychiatric clinical pharmacists practice within their scope of practice, and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2019
The Facility Director ensures the development of a collaborative agreement and/or policy to address specific conditions that require oversight of psychiatric clinical pharmacists by psychiatrists in the Mental Health Service.
Comprehensive Healthcare Inspection Program Review of the VA Palo Alto Health Care System, California
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18-00617-227

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that the Patient Safety Manager reports and documents all patient safety incidents using the Joint Patient Safety Reporting System and monitors the Patient Safety Manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that the Patient Safety Manager submits annual reports to the leadership team for review and monitors the Patient Safety Manager’s compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/7/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/31/2018
The Associate Director ensures the VA Police test panic alarms at the San Jose community based outpatient clinic regularly and monitors VA Police compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that controlled substances inspectors complete monthly inspections of assigned areas and that controlled substances coordinators refrain from conducting routine inspections, and the Facility Director monitors program inspectors’ and coordinators’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The Chief of Staff ensures that the geriatric evaluation program quality improvement data are reviewed and reported to the Quality, Safety and Value Council and monitors compliance.
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