All Reports

Comprehensive Healthcare Inspection Program Review of the Battle Creek VA Medical Center, Michigan
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18-01139-267

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Director ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2019
The Chief of Staff ensures that clinical managers initiate and complete Focused Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2019
The Chief of Staff ensures that clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi
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18-00608-247

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Facility Director ensures that an interdisciplinary facility group reviews utilization management data and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to Facility leaders at the completion of each fiscal year and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/15/2019
The Chief of Staff ensures that Executive Committee of the Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion in order to recommend approval of clinical privileges for licensed independent practitioners and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/9/2019
The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired licensed independent practitioners and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2020
The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/10/2020
The Associate Director ensures required team member participate in environment of care rounds and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2019
The Associate Director ensures sterilized surgical instruments in the podiatry clinic are appropriately labeled with expiration dates or statements and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that the Alternate Controlled Substance Coordinator’s position description or functional statement includes an addendum for the Controlled Substance Coordinator’s duties and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that monthly controlled substance inspections are completed in all required areas and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/10/2019
The Facility Director ensures that all controlled substance inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2019
The Facility Director ensures that required pharmacy inspections are completed monthly and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2020
The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive Posttraumatic Stress Disorder screens and monitors compliance.
VA Policy for Administering Traumatic Brain Injury Examinations
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16-04558-249

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/10/2018
The Under Secretary for Benefits coordinate with the Under Secretary for Health to determine whether veterans who had received initial TBI medical examinations by VHA-contracted examiners and not by one of the four designated specialists, were unintentionally excluded from equitable relief. If additional veterans are identified, the OIG requests that those cases be referred to the VA Secretary for consideration of equitable relief.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/13/2019
The Under Secretary for Benefits confirm whether the names of veterans who were not on the initial list of veterans entitled to equitable relief and later identified by VBA staff and referred for potential equitable relief were submitted to the VA Secretary for consideration. The OIG requests an update of the current status and disposition of those cases.
Review of Accuracy of Reported Pending Disability Claims Backlog Statistics
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16-02103-265

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/3/2019
The OIG recommended the Under Secretary for Benefits consider revising which claims are included in VBA’s reported disability claims backlog and provide a clear definition to all stakeholders.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/28/2019
The OIG recommended the Under Secretary for Benefits implement a plan to provide consistent oversight and training of Claims Assistants through national performance and training plans.
Bulk Payments Made under Patient-Centered Community Care/Veterans Choice Program Contracts
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17-02713-231

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
The Executive in Charge, Office of the Under Secretary for Health, continue to support processes to prevent duplicate payments made to third-party administrators through the bulk payment process and ensure that proper controls are in place to prevent duplicate payments to third-party administrators through all other current payment methodologies and under future Community Care contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/2/2019
The Executive in Charge, Office of Under Secretary for Health, ensure that Office of Community Care staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant government authorities to review and determine an appropriate process for reimbursement of overpayments by the third-party administrators.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 101,400,000.00
Comprehensive Healthcare Inspection Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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18-01013-263

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2019
The Associate Director ensures the VA Police regularly test panic alarms at the Hot Springs community based outpatient clinic and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing at the locked mental health unit and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/5/2019
The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures that reconciliation of controlled substances dispensing from the pharmacy to every automated dispensing cabinet and returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures that controlled substances inspectors verify written controlled substance orders during monthly area inspections and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures controlled substances inspectors complete emergency drug cache inspections and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/17/2019
The Chief of Staff ensures providers complete suicide risk assessments within the required timeframe for patients with positive post-traumatic stress disorder screens and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2019
The Facility Director ensures that the Joint Leadership Council maintain oversight of all geriatric evaluation program performance improvement activities and monitors compliance.
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.
Accuracy of Effective Dates for Reduced Evaluations Needs Improvement
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17-05244-226

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2018
The Under Secretary for Veterans Benefits Administration implement a plan to ensure staff timely process cases with reduced evaluations, after the decision, to prevent rework and improper payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/12/2020
The Under Secretary for Veterans Benefits Administration establish a plan to modify the Veterans Benefits Management System to apply correct effective dates for cases with reduced evaluations for conditions that were no longer service-connected and alert staff when the assigned effective dates are improper.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/29/2018
The Under Secretary for Veterans Benefits Administration remind VA Regional Office staff of the system defect that causes effective dates to be one month later than required for conditions that are no longer being classified as service-connected, until the Veterans Benefits Administration could implement a system change.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/28/2019
The Under Secretary for Veterans Benefits Administration implement a plan to provide refresher training on the proper processing of reduced evaluations to staff who process rating reductions and monitor the effectiveness of that training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/7/2019
The Under Secretary for Veterans Benefits Administration provide updated guidance to include provisions for when amended proposal letters are necessary.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/8/2021
The Under Secretary for Veterans Benefits Administration implement a plan to conduct periodic reviews for veterans who had evaluations reduced after the first of the month following the final notification letter and before the first of the month following 60 days after the final notification letter, take corrective actions as needed, and provide certification of completion to the Office of Inspector General.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 37,900,000.00
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
|
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
|
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
|
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
|
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
|
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.
Postoperative Care Concerns for a Vascular Surgical Patient at the Martinsburg VA Medical Center, West Virginia
|
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.
Program of Comprehensive Assistance for Family Caregivers: Management Improvements Needed
|
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
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
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18-00619-242

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: 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.
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