All Reports

Healthcare Inspection – Alleged Women’s Health Care Issues, Gulf Coast Veterans Health Care System, Biloxi, Mississippi
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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.
Comprehensive Healthcare Inspection Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico
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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 - Patient Mental Health Care Issues at a Veterans Integrated Service Network 16 Facility
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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
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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
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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
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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
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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.
Audit of VHA’s Management of Primary Care Panels
|
15-03364-380

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/30/2020
The OIG recommended the Acting Under Secretary for Health establish standardized primary care scheduling processes that provide newly enrolled veterans an opportunity to schedule an appointment at the time of enrollment.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2018
The OIG recommended the Acting Under Secretary for Health establish metrics to monitor the time it takes facilities to offer scheduling for an initial primary care appointment, beginning with the date the veteran submits a completed enrollment form.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/15/2019
The OIG recommended the Acting Under Secretary for Health improve oversight by ensuring facilities set panel sizes consistent with VHA’s recommended model panel sizes, submit written justification for panel sizes that deviate from VHA’s model panel sizes for review and approval by VHA, or implement corrective action to mandate appropriate panel size.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 843,000,000.00
Review of Alleged Appeals Data Manipulation at the VA Regional Office, Roanoke, Virginia
|
17-00397-364

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/16/2018
The OIG recommended the Roanoke VA Regional Office Director conduct a review to identify prematurely closed appeals records, confer with appropriate VBA officials to determine the proper corrective actions to take, if any, and provide certification of completion of the review to the Office of Inspector General.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 10/1/2018
The OIG recommended the Roanoke VA Regional Office Director confer with Regional Counsel to determine what steps to take, if any, with regard to management or staff involved in the conduct discussed in this report.
Healthcare Inspection—Unexpected Death of a Patient: Alleged Methadone Overdose, Grand Junction VA Health Care System, Grand Junction, CO
|
16-04208-30

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2018
We recommended that the System Director ensure that providers who prescribe methadone receive education on VA/DoD Clinical Practice Guideline recommendations related to the use of methadone for the management of chronic pain.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2017
We recommended that the System Director develop a process to ensure that providers consider VA/DoD Clinical Practice Guideline recommendations, specifically the use of electrocardiograms, in their clinical decision to prescribe methadone for chronic pain management.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2018
We recommended that the System Director ensure that patients receiving methadone be informed, not only of complications related to opioids but also, complications specific to methadone and that this discussion is documented.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/1/2018
We recommended that the System Director ensure that the consent form for patients receiving methadone for chronic pain management be modified to include methadone-specific risks.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2017
We recommended that the System Director confer with the Office of Chief Counsel regarding the patient described in this report for possible institutional disclosure to the designated family member(s), and take action as appropriate.
Comprehensive Healthcare Inspection Program Review of the VA Long Beach Healthcare System, Long Beach, California
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17-01739-31

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2018
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: 6/27/2018
The Associate Director for Patient Care Services ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2018
The Chief of Staff ensures that for patients transferred out of the facility, providers consistently include patient or surrogate informed consent and medical and/or behavioral stability in transfer documentation and monitors providers’ compliance
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2018
The Chief of Staff ensures transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitors acceptable designees’ compliance
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The Chief of Staff ensures that for inter-facility transfers, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Assistant Director ensures that facility managers maintain a safe and clean environment throughout the facility and the Santa Ana Outpatient Primary Care Clinic and monitors the managers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2017
The Chief of Staff ensures that facility managers conduct annual infection prevention risk assessments.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2018
The Assistant Director ensures that dirty and used equipment is stored separately from sterile supplies.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2018
The Assistant Director ensures that staff regularly test panic alarms at the Santa Ana Outpatient Primary Care Clinic.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Assistant Director ensures that staff regularly test camera surveillance equipment on the locked mental health unit and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/8/2018
The Assistant Director ensures that the locked mental health unit clean/sterile supply rooms are clean and that used equipment is stored separately from sterile supplies.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The Chief of Staff and Associate Director for Patient Care Services ensure the Community Nursing Home Oversight Committee includes representation by all required disciplines.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/17/2018
The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
The Associate Director for Patient Care Services ensures that the social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitors the social workers’ and registered nurses’ compliance.
Comprehensive Healthcare Inspection Program Review of the James J. Peters VA Medical Center, Bronx, New York
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17-01751-25

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures the Quality Executive Board meets monthly as required by facility policy, or facility leaders revise the local policy to be consistent with Veterans Health Administration quarterly meeting requirements, and the Facility Director monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data twice per year and monitors the managers’ compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures clinical managers complete at least 75 percent of allrequired inpatient utilization management reviews and monitors the managers’compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Chief of Staff ensures identification of an interdisciplinary group or committee, ensures review of utilization management data on an ongoing basis, and monitors the group’s compliance with data review policies.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures all required anticoagulation management programquality assurance data are collected, analyzed, and reported biannually at Pharmacyand Therapeutics Committee meetings and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
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: 8/6/2018
The Chief of Staff ensures mental health providers consistently document patient or surrogate informed consent and identify the receiving provider when patients are transferred out of the facility and monitors the providers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2018
The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2018
The Associate Director ensures the locked mental health unit’s security surveillance television system is included in the annual physical security assessment and is regularly tested and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/29/2017
The Associate Director ensures all members of the Interdisciplinary Safety Inspection Team 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 compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Facility Director ensures that the use of reversal agents in moderate sedation cases and the presence or absence of adverse events are reported to and trended by the Performance Improvement Committee and monitors compliance.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2018
The Chief of Staff ensures providers perform history and physical exams within 30 days prior to the moderate sedation procedure and include all required elements in the history and physical exams and/or pre-sedation assessments and monitors providers’ compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2018
The Chief of Staff ensures clinical employees who perform, assist with, or supervise moderate sedation procedures have current Basic Life Support certification and moderate sedation training and monitors their compliance.
Review of VA's Reimbursements to the Treasury Judgment Fund
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17-00833-05

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 7/11/2018
We recommended the Acting Assistant Secretary for Management and Acting Chief Financial Officer establish procedures to ensure VA reimburses the Treasury Judgment Fund within 45 business days of receipt of requests for reimbursement or establishes appropriate payment plans for claims paid pursuant to applicable law.
Review of Alleged Use of Inappropriate Wait Lists for Group Therapy and Post Traumatic Stress Disorder Clinic Team, Eastern Colorado Health Care System
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17-00414-376

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2018
The OIG recommended the director of the Eastern Colorado Health Care System ensure mental health staff schedule veterans for appointments or add them to the electronic wait lists when acting on care requests.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/22/2018
The OIG recommended the director of the Eastern Colorado Health Care System ensure that Colorado Springs resources are sufficient to process PCT consult requests within seven days of receipt.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2017
The OIG recommended the director of the Eastern Colorado Health Care System ensure that Colorado Springs PCT staff enter the clinically indicated date from the consult when scheduling veterans’ appointments.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2017
The OIG recommended the director of the Eastern Colorado Health Care System ensure that Colorado Springs PCT staff enter consult actions, including scheduling efforts, in the electronic health record.
Healthcare Inspection – Mental Health Care Concerns, Atlantic County Community Based Outpatient Clinic, Northfield, New Jersey
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16-03519-28

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that the Veterans Integrated Service Network Director ensure that Atlantic County Community Based Outpatient Clinic schedulers determine and document appointment dates using clinically indicated and desired/preferred dates and facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process for management of established mental health patients seeking an unscheduled appointment that includes communication between patients and clinical and administrative staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process including a definition of supervisor responsibilities for oversight and auditing of scheduling and no-shows, and facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process to manage patients who still need care when Community Based Outpatient Clinic staff have cancelled appointments, and facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/20/2018
We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement the Community Based Outpatient Clinic Mental Health services termination process as outlined in local policy.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
We recommended that the Veterans Integrated Service Network Director ensure the Facility Director implements oversight processes that ensure non-VA care coordination staff follow-up on all consults in a timely manner and facility managers monitor compliance.
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