All Reports

Combined Assessment Program Summary Report— Management of Disruptive and Violent Behavior in Veterans Health Administration Facilities
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17-04460-84

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure Facility Directors establish Employee Threat Assessment Teams.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require attendance by VA Police Officers, Patient Safety and/or Risk Management Officials, and Patient Advocates at Disruptive Behavior Committee/Board meetings and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/17/2019
OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when Chiefs of Staff (or designees) issue Orders for Behavioral Restriction, they document that they informed patients that the Orders were issued and of the right to appeal the decisions and that facility senior managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2020
OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require that within 90 days of hire, all employees complete Level I Prevention and Management of Disruptive Behavior training and additional training levels based on the type and severity of risk for exposure to disruptive and unsafe behaviors and monitor compliance.
Healthcare Inspection – Primary Care Provider’s Clinical Practice Deficiencies and Security Concerns, Fort Benning VA Clinic, Fort Benning, Georgia
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16-03405-80

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2018
We recommended that the Veterans Integrated Service Network Director ensure that the System Director evaluates the care of the subject patient (Patient 1) and consults with the Office of General Counsel for disclosure to the patient, if appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/11/2018
We recommended that the Veterans Integrated Service Network Director ensure that the System Director consults with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action(s), if any, for Primary Care Provider X and Primary Care Provider X’s supervisors.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2018
We recommended that the System Director ensure that providers notify patients of test values and follow up on clinical laboratory results as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2018
We recommended that the System Director ensure that providers accurately document patients’ assessment, diagnosis, and treatment information into the electronic health record.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
We recommended that the System Director ensure that consults for VHA and non-VA care are entered and completed within time frames set by Veterans Health Administration.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2018
We recommended that the System Director ensure that employees receive training appropriate for the assigned Workplace Behavioral Risk Assessment risk level.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2018
We recommended that the System Director ensure that Clinic employees are trained in emergency management procedures.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/28/2018
We recommended that the System Director ensure that emergency procedures and contact information are posted and readily available to Clinic employees.
Comprehensive Healthcare Inspection Program Review of the Grand Junction Veterans Health Care System, Grand Junction, Colorado
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17-01744-69

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2018
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: 6/12/2018
The Facility Director ensures the Patient Safety Manager consistently provides feedback to employees or departments who submit close call and adverse event reports that result in a root cause analysis and monitors the manager’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2018
The Chief of Staff ensures anticoagulation program managers establish a defined process for anticoagulation-related calls outside normal business hours and monitors compliance with the process.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2018
The Chief of Staff ensures the Pharmacy and Therapeutics Committee reviews anticoagulation data quarterly and monitors the committee’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2018
The Facility Director ensures inter-facility patient transfer data are reported to a quality oversight committee and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2018
The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include in transfer documentation patient or surrogate informed consent and monitors the clinicians’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2018
The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently document sending or communicating pertinent patient information to the receiving facility and monitors the clinicians’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2018
The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors employees’ and team members’ compliance.
Audit of VHA's Use of Appropriations to Develop a System Enhancement and Mobile Health Application
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15-01005-18

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2018
The OIG recommended the Acting Assistant Secretary for the Office of Information and Technology ensure the new directive reflects updates so that new and emerging advances in information technology are included.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2018
The OIG recommended the Acting Under Secretary for Health ensure VHA’s Chief Financial Officer, in consultation with VA’s Chief Financial Officer and Office of General Counsel, determine which medical care appropriation VHA should use for mobile health application development and notify VHA staff offices accordingly.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2018
The OIG recommended the Acting Assistant Secretary for the Office of Management issue a memorandum reiterating the importance of complying with the United States Code, Federal Regulations, and VA’s current policies on the proper use of appropriations.
Healthcare Inspection – Delays in Processing Release of Information Requests, Bay Pines VA Healthcare System, Bay Pines, Florida
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16-02864-71

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/17/2018
We recommended that the System Director ensure strengthening of procedures for timely processing of Release of Information requests.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
We recommended that the System Director strengthen the process to adequately capture and trend complaints related to Release of Information requests in accordance with Veterans Health Administration policy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/6/2019
We recommended that the System Director ensure an evaluation of the personnel issues negatively impacting staff retention and hiring in the Release of Information section and take appropriate action.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
We recommended that the System Director ensure accurate monitoring of Release of Information staff productivity.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
We recommended that the System Director ensure accurate and effective trackingand monitoring processes of Release of Information requests.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/10/2018
We recommended that the System Director ensure consultation with the Office ofHuman Resources and the Office of General Counsel to determine the appropriateadministrative action, if any, for managers’ performance related to implementation ofcorrective action plans in response to privacy violations.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the System Director ensure Release of Information standardoperating procedures are established in accordance with VHA policy and implemented consistently.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
We recommended that the System Director strengthen working relationships andcommunication processes within the facility Release of Information section andamongst staff and Business Office Service managers.
Comprehensive Healthcare Inspection Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon
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17-01740-62

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2018
The Facility Director requires the Patient Safety Manager to ensure completion of the required minimum of eight root cause analyses each fiscal year.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/5/2018
The Chief of Staff requires the Pharmacy and Therapeutics Committee to review all quality assurance data for the anticoagulation management program and monitors the committee’s compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2018
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 Benefits Administration (VBA)
Closure Date: 8/1/2018
The Chief of Staff ensures management-level representatives from all required disciplines consistently attend Community Nursing Home Oversight Committee meetings and monitors their compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2018
The Chief of Staff ensures social workers conduct cyclical clinical visits with the required frequency and monitors the social workers’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2018
The Chief of Staff ensures Mental Health Residential Rehabilitation Treatment Program employees perform and document weekly contraband inspections and monitors employees’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2018
The Associate Director ensures that closed circuit television surveillance systems are repaired or replaced for all required areas in the Mental Health Residential Rehabilitation Treatment Program units.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2018
The Chief of Staff ensures the Mental Health Residential Rehabilitation Treatment Program units have signage alerting patients and visitors of closed circuit television recording.
Comprehensive Healthcare Inspection Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota
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17-01755-61

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors advisors’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2018
The Facility Director ensures the Patient Safety Manager submits an annual patient safety report to facility leaders at the completion of each fiscal year and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Facility Director and Chief of Staff ensure that Executive Leadership Board and Peer Review Committee meeting minutes accurately reflect action status and that items are tracked to closure and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Associate Director for Patient Care Services ensures the anticoagulation management program policy is revised to include the transition of patients between the inpatient and outpatient care settings and an anticoagulation quality assurance program.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The Chief of Staff and Associate Director for Patient Care Services ensure that anticoagulation management program quality assurance data from all sites of care are collected, analyzed, and reported biannually to the Pharmacy and Therapeutics Committee and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2018
The Associate Director for Patient Care Services ensures that annual anticoagulation management program competency assessments include all required content and that employees assigned to this program complete competency assessments as required and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Facility Director ensures the facility’s revised inter-facility transfer policy includes all required elements.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for patients transferred out of the facility, providers consistently document patient or surrogate informed consent, medical and behavioral stability, and identification of transferring and receiving provider or designee and monitors providers’ compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Associate Director for Operations ensures designated team members conduct environment of care rounds in clinical and nonclinical areas as required and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Associate Director for Operations ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/28/2018
The Chief of Staff ensures that providers include an airway assessment and history of previous adverse experience with sedation or anesthesia in the history and physical exam and/or pre-sedation assessment and monitors the providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2018
The Chief of Staff ensures that providers provide and document informed consent prior to moderate sedation administration and monitors providers’ compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The Chief of Staff ensures clinical teams conduct and document timeouts prior to moderate sedation procedures, the privileged provider participates in the timeout, and staff use a checklist that includes all required elements and monitors compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/3/2018
The Chief of Staff ensures Community Nursing Home Oversight Committee meetings include participation by all required disciplines and monitors compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/27/2018
The Associate Director for Patient Care Services ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.
Audit of Medical Support Assistant Workforce Management at the Phoenix VA Health Care System
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16-00928-391

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2018
The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements controls to make sure sufficient information on the outpatient Medical Support Assistant workforce is captured and documented to allow leadership to align strategically this workforce with outpatient clinical operations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2018
The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements mechanisms to make certain that Human Resources Management Service personnel record complete and accurate Medical Support Assistant recruitment and hiring data and documentation in the USA Staffing System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2018
The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System leverages available incentives to the extent practicable to recruit and retain qualified applicants for human resources specialist positions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2018
The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements the Hire Right Hire Fast program’s best practices to improve the timeliness of the Medical Support Assistant selection process.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2018
The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements controls to make certain newly hired Medical Support Assistants are provided with timely performance plans in accordance with VA Handbook 5013/12.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/9/2018
The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System evaluates the feasibility of using available employee survey data to identify and redress the reasons why Medical Support Assistants leave their current positions.
Comprehensive Healthcare Inspection Program Review of the South Texas Veterans Health Care System, San Antonio, Texas
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17-01852-59

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2018
The Assistant Director ensures damaged sink counters on the cardiac intensive care unit are repaired.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
The Chief of Staff and Associate Director for Patient Care Services ensure locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2018
The Associate Director for Patient Care Services ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors their compliance.
Comprehensive Healthcare Inspection Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico
|
17-01741-58

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data quarterly and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Associate Director for Patient Care Services ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Associate Director ensures quality assurance data for the anticoagulation management program are reviewed at the Pharmacy and Therapeutics Committee and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Chief of Staff ensures clinicians provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures clinicians obtain required laboratory tests prior to initiating anticoagulant medications and monitors the clinicians’ compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Associate Director ensures all required elements specific to anticoagulation management are included in competency assessments for all employees actively involved in the anticoagulant program and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee assigned these responsibilities and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Associate Director for Patient Care Services ensures providers consistently document patient or surrogate informed consent and patient medical and behavioral stability and identify transferring providers or designees for patients transferred out of the facility and monitors providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/19/2018
The Associate Director for Patient Care Services ensures that, for inter-facility transfers, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures environment of care inspections are conducted at the required frequency and documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures core team members consistently participate in environment of care rounds and attendance is documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures that in patient care areas, floors and rolling equipment are clean, nourishment kitchen ice machines are clean, and damaged furniture is repaired or removed from service and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures outdated supplies are removed from the Santa Fe VA Clinic and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Assistant Director ensures facility managers complete a physical security assessment for the locked geriatric mental health unit.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Assistant Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, to include the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures that providers include the accurate name of the provider performing the procedure on the informed consent and monitors providers’ compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures the privileged providers performing the procedure participate in the timeout process prior to moderate sedation procedures and monitors providers’ compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures clinical teams use a checklist that includes all required elements to conduct and document timeouts prior to moderate sedation procedures and monitors compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by all required disciplines and monitors compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
The Chief of Staff ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.
Healthcare Inspection – Alleged Women’s Health Care Issues, Gulf Coast Veterans Health Care System, Biloxi, Mississippi
|
16-03705-60

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/29/2018
We recommended that the System Director ensure that system primary care providers receive education on Veterans Health Administration cervical cancer screening guidelines and that supervisors monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the System Director review and evaluate the routine use of general anesthesia for loop electrosurgical excision procedures conducted in the operating room and take action as appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
We recommended that the System Director utilize Veterans Health Administration resources to promote a culture that discourages behaviors that undermine safe patient care and effective communication and collaboration between providers and between providers and patients.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
We recommended that the System Director ensure that care coordination agreements between primary care and gynecology services meet system annual review requirements.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2018
We recommended that the System Director ensure that Patient Advocacy Program managers enter all complaints into the Patient Advocacy Tracking System database and track all reported complaints to resolution.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/11/2018
We recommended that the System Director ensure that system gynecologists have current privileges that meet Veterans Health Administration and system policy requirements.
Healthcare Inspection - Patient Mental Health Care Issues at a Veterans Integrated Service Network 16 Facility
|
16-03576-53

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Facility Director ensure usage of only approved policies regarding use of benzodiazepines and facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/4/2019
We recommended that the Facility Director ensure facility managers revise the patient complaint policy to include the VHA requirement for a clinical appeals process and to educate clinicians about the VHA requirement for clinical appeals and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
We recommended that the Facility Director ensure that the Psychosocial Residential Rehabilitation Treatment Program committee admission screening process isappropriate and timely and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Facility Director ensure that mental health clinicians administer tuberculosis tests (purified protein derivative) when needed forPsychosocial Residential Rehabilitation Treatment Program admission and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
We recommended that the Facility Director ensure that Mental Health services areprovided timely for patients designated as high risk for suicide that have beenrecently discharged from community hospitals.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/1/2020
We recommended that the Facility Director ensure that non-VA care for psychiatricservices is offered to patients who need to be seen sooner than VA appointmentavailability permits.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Facility Director request that the Veterans IntegratedService Network Mental Health Program Manager evaluate facility Mental HealthServices and programs for opportunities for improvement.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
We recommended that the Facility Director ensure that a Mental Health Treatment Coordinator policy is implemented as required by the Veterans Health Administrationand that all patients receiving mental health services are assigned a Mental Health Treatment Coordinator.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Facility Director ensure compliance with medication reconciliation as required by facility policies.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
We recommended that the Facility Director ensure that Suicide Behavior Reports are completed for all patient suicide attempts and that the Patient Safety Manager is added as a signer as required by facility policy.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2018
We recommended that the Facility Director ensure that a peer review screening is completed for patients who have attempted suicide within 30 days of seeing a health care professional as required by facility policy.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/5/2018
We recommended that the Facility Director initiate an external peer review to determine whether mental health staff appropriately managed the patient’s bipolar illness. Based on the results of that peer review, the Facility Director should consult with the Office of Chief Counsel regarding an institutional disclosure, if appropriate.
Administrative Investigation – Improper Locality Pay, Office of the General Counsel, Pacific District South, Phoenix, Arizona
|
17-02375-50

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 1/8/2018
We recommend that the General Counsel determine whether Ms. (redacted) official duty station from July 2016 to December 2016 was Phoenix or Los Angeles.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to General Counsel (OGC)
Closure Date: 8/13/2018
We recommend that if the General Counsel determines Ms. (redacted) official duty station from July 2016 to December 2016 was Phoenix, determine the total amount of locality pay improperly paid to her, and issue her a bill of collection in that amount.
Administrative Investigation – Improper Relocation Allowance and Market Pay, Veterans Health Administration, Washington, DC
|
16-02552-49

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/22/2018
We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Dr. West.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/22/2018
We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Dr. Lynch.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/22/2018
We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of General Counsel and Human Resources and issue Dr. West a bill of collection in the amount of $19,800 to reimburse VA for the lump sum TQSE payment he received but did not incur.
No. 4
Not Implemented Recommendation Image, X character'
to Veterans Health Administration (VHA)
Closure Date: 1/2/2018
We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of General Counsel and Human Resources and issue Dr. West a bill of collection in the amount of $55,434 to reimburse VA for the increase salary he received based on Washington, DC, market pay, from September 2013 to October 2016, when he was actually located in Salt Lake City, UT.
Audit of VHA’s Timeliness and Accuracy of Choice Payments Processed Through FBCS
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15-03036-47

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/21/2021
We recommended the Executive in Charge, Veterans Health Administration, develop and issue written payment policies to guide staff processing medical claims received from Third Party Administrators, as well as establish expectations and obligations for the Third Party Administrators that submit invoices for payment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
We recommended the Executive in Charge, Veterans Health Administration, ensure payment processing staff have access to documentation from the Third Party Administrators verifying amounts paid to providers to ensure the Third Party Administrators are not billing VA more than they paid the provider for medical claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/2/2021
We recommended the Executive in Charge, Veterans Health Administration, ensure Veterans Health Administration payment staff have access to accurate data regarding veterans’ other health insurance coverage and establish appropriate processes for collecting payments from these health insurers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/31/2021
We recommended the Executive in Charge, Veterans Health Administration, ensure the new payment processing systems used for processing medical claims from Third Party Administrators have the ability to adjudicate reimbursement rates accurately and to ensure duplicate claims are not paid.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2021
We recommended the Executive in Charge, Veterans Health Administration, ensure VA performs post-payment audits on a periodic basis to determine if payments made to Third Party Administrators for medical care are accurate.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/10/2020
We recommended the Executive in Charge, Veterans Health Administration, 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.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/4/2019
We recommended the Executive in Charge, Veterans Health Administration, ensure the Veterans Health Administration has sufficient claims processing capacity to timely meet and process expected claim volume from the Third Party Administrators.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/11/2018
We recommended the Executive in Charge, Veterans Health Administration, ensure that future contracts with Third Party Administrators contain payment timeliness standards for the processing of claims from health care providers.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 39,000,000.00
Comprehensive Healthcare Inspection Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan
|
17-01849-42

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2018
The Chief of Staff and Associate Director for Patient Care Services ensure clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitor clinicians’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2018
The Associate Director for Patient Care Services ensures clinical managers include in competency assessments of employees actively involved in the anticoagulant program knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy, and the Associate Director for Patient Care Services monitors managers’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2018
The Associate Director ensures damaged furnishings in patient care areas are repaired or removed from service.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
The Associate Director ensures panic alarms at the Veterans Community Resource and Referral Center are tested and testing is documented and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/31/2018
The Associate Director ensures radiation shields and aprons have evidence of periodic inspection and testing for integrity and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/15/2018
The Associate Director ensures radiology equipment consistently receives annual inspection by a medical physicist and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2018
The Associate Director ensures Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors team members’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/4/2018
The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors their compliance.
Review of Alleged Mismanagement of VA’s Real Time Location System Project
|
15-05447-383

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 2/1/2019
The OIG recommended that the Acting Under Secretary for Health, in conjunction with the Acting Assistant Secretary for Information and Technology, apply additional resources and implement improved integrated project management controls for the remainder of the Real Time Location System project to restrict further cost increases.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 2/1/2019
The OIG recommended that the Acting Under Secretary for Health, in conjunction with the Acting Assistant Secretary for Information and Technology, enforce the use of incremental project management controls, such as those used within the Veteran-focused Integration Process, on all remaining Real Time Location System task orders to ensure such efforts will provide an adequate return on investment.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 7/16/2018
The OIG recommended the Acting Assistant Secretary for the Office of Information and Technology ensure that risk assessments are conducted on future Real Time Location System deployments to identify potential risks and vulnerabilities that may adversely affect other VA systems.
Audit of VHA's Alleged Beneficiary Travel Processing Irregularities at the VAMC in Phoenix, Arizona
|
16-00471-10

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2018
We recommended the Director of the Carl T. Hayden VA Medical Center develop and implement written procedures requiring Beneficiary Travel Program and Fiscal Service staff to perform appropriate actions in response to electronic alerts notifying them of potential duplicate claims and payments.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/24/2018
We recommended the Director of the Carl T. Hayden VA Medical Center develop and implement a quality review program to routinely ensure Beneficiary Travel Program staff document and use physical addresses when calculating mileage reimbursements.
Comprehensive Healthcare Inspection Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas
|
17-01850-38

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/13/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2019
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. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/13/2018
The Chief of Staff ensures clinicians consistently provide specific education to all patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2019
The Assistant Director ensures all Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/17/2019
The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors their compliance.
Comprehensive Healthcare Inspection Program Review of the Bath VA Medical Center, Bath, New York
|
17-01752-32

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/26/2019
The Chief of Staff ensures that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2018
The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2018
The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
The Associate Director ensures that an inventory of the required number of filled oxygen tanks is maintained at the Wellsboro VA Clinic and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2018
The Associate Director ensures that an adequate supply of personal protective equipment (masks, gloves, gowns, and goggles) is available for employees at the Wellsboro VA Clinic and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
The Associate Director ensures that clean and sterile supplies are stored on supply room carts that have solid bottom shelves at the Wellsboro VA Clinic and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/23/2018
The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program employees conduct and document monthly self-inspections, weekly contraband inspections, every 2-hour rounds of all public spaces, and daily resident room inspections for unsecured medications and monitors employees’ compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/15/2019
The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program managers ensure the main point of entry has a keyless system and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/10/2018
The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program managers ensure all non-main entrance doors are locked to prevent unauthorized entry and alarmed at all times and monitors compliance.
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