All Reports

Alleged Inappropriate Controlled Substance Prescribing Practices at a Veterans Integrated Service Network 20 Medical Facility
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16-05323-200

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
Veterans Integrated Service Network 20 Director conducts a management review of the care of the patient who is the subject of this report, and confers with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
The Facility Director implements a systematic approach to review prescribing of controlled substances to individuals at high-risk for substance abuse or misuse.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
The Facility Director strengthens processes that foster interdisciplinary collaboration for the management of patients with complex clinical pain and allows referrals from all Facility staff.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director ensures that policy and practice is consistent with Veterans Health Administration Directive 1005, Informed Consent for Long-term Opioid Therapy for Pain.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/20/2019
The Facility Director ensures provider accountability for compliance with Veterans Health Administration and Facility controlled substance policies, including opioid informed consent policies.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/8/2019
The Facility Director strengthens the Facility Board that is responsible for controlled substances safety, including clarification of roles, responsibilities, and authority; and the development of clearly written definitions and entry criteria for Category II patient record flags in accordance with Veterans Health Administration policy.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director maintains full compliance with the Veterans Health Administration’s peer review directive, including but not limited to the selection of impartial reviewers and removing the service chief level review from the Facility peer review process.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Facility Director performs a focused professional practice evaluation on primary care provider 1’s opioid prescribing practices in high-risk patients.
Alleged Inappropriate Anesthesia Practices at the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania
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16-00284-214

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The James E. Van Zandt VA Medical Center Director ensures that the James E. Van Zandt VA Medical Center’s anesthesia needs and services are evaluated and align with Veterans Health Administration and James E. Van Zandt VA Medical Center policies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2018
The James E. Van Zandt VA Medical Center Director ensures that service chief provider oversight includes facility-specific privileges and provider-specific Ongoing Professional Practice Evaluations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/16/2018
The James E. Van Zandt VA Medical Center Director ensures that James E. Van Zandt VA Medical Center leaders consult with the Office of Chief Counsel to determine if the anesthesiologist should be reported to the National Practitioner Data Bank and the State Licensing Board for administrating medications inconsistent with the Food and Drug Administration approved manufacturer’s instructions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/5/2018
The James E. Van Zandt VA Medical Center Director ensures that the Patient Advocate enters all patient complaints into the Patient Advocate Tracking Systems database; documents issue descriptions and actions taken; and tracks all complaints to resolution.
Patient Overdose Death in a Residential Rehabilitation Treatment Program at a VISN 1 Medical Facility
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17-04354-187

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The VISN 1 Medical Facility Director ensures that staff receive education about the process for initiating Medication Assisted Therapy for patients enrolled in the Program.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The VISN 1 Medical Facility Director ensures that a standard operating procedure is issued to effectively track patients enrolled in the Program who fail to show for appointments at off-site substance abuse day programs.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/13/2018
The VISN 1 Medical Facility Director ensures that all appropriate staff receive training regarding the standard operating procedure for tracking patients enrolled in the Program who fail to show for appointments in at off-site substance abuse day programs.
VA Southern Nevada Healthcare System's Alleged Unnecessary Use of Outside Vendors to Purchase Prosthetics
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16-02247-165

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 21 Director ensures the Director of the VA Southern Nevada Healthcare System develops and implements effective processes such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetics Laboratory operates in a manner that maximizes its personnel and on hand inventory to provide veterans with timely and cost effective fitting services for compression garments and orthotic shoes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 22 Director ensures the VA San Diego Healthcare System Director takes steps such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetic Service operates in a manner that maximizes its resources to provide veterans with timely and cost effective fitting services compression garments and orthotic shoes.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements effective processes to monitor purchasing employees’ usage of all non item Healthcare Common Procedure Coding System codes to ensure the proper utilization of these codes.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements a process to examine the 4,530 consults closed, but not cloned, by purchasing employees using the NR018 code from October 2014 through May 2016 and take necessary action to ensure veterans received their prescribed prosthetic or orthotic item(s).
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 242,000.00
Comprehensive Healthcare Inspection Program Review of the VA Hudson Valley Health Care System, Montrose, New York
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17-05399-194

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Chief of Staff ensures that Facility clinical managers consistently initiate Focused Professional Practice Evaluations and that they are completed by providers with similar training and privileges and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Associate Director ensures all required team members consistently participate on environment of care rounds and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Associate Director ensures damaged or soiled furnishings and equipment in patient care areas are sanitized, repaired, or removed from service and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/26/2018
The Associate Director ensures that shower soap dispensers in the acute Mental Health Unit are replaced as required by 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: 2/21/2019
The Facility Director ensures that all Controlled Substance Inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/15/2018
The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the Memphis VA Medical Center
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18-00609-185

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Facility Director ensures Facility staff enter all patient incidents into WebSPOT or the VHA Patient Safety Information System and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired Licensed Independent Providers and monitors compliance
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Chief of Staff ensures that service chiefs include review of relevant data in Ongoing Professional Practice Evaluations to determine continuation of current privileging for Licensed Independent Providers and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2019
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2019
The Associate Director ensures Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Associate Director ensures that bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/18/2019
The Associate Director ensures clinical staff remove expired medications from patient care areas and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2019
The Associate Director ensures the Facility managers maintain a safe and clean environment at the Covington North Community Based Outpatient Clinic and monitors compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2019
The Associate Director ensures that Community Based Outpatient Clinic staff maintain clear means of egress at the Covington North Community Based Outpatient Clinic and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Associate Director ensures that environmental management service staff maintain clean air ducts and ventilation grills in food service and storage areas and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Facility Director ensures the Controlled Substance Coordinator completes and documents annual controlled substance inspector training and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/18/2019
The Chief of Staff ensures that Geriatric and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/27/2018
The Associate Director for Patient Care Services ensures that all staff involved in managing central lines receive central line-associated bloodstream infection prevention education and monitors compliance.
Alleged Mismanagement of Inpatient Care at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas
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17-02484-189

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
The System Director ensures provider privileges are facility-specific as required by Veterans Health Administration Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
The System Director ensures the System’s Bylaws and Rules of the Medical Staff are updated to reflect compatibility and compliance with 38 CFR 17.415, Full Practice Authority for Advance Practice Registered Nurses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
The System Director ensures the Facility meets the requirements for physician staffing for inpatient coverage, pre-operative risk and anesthesia assessments, and anesthesia services in-house coverage as required by Veterans Health Administration Directive 2010-018, Facility Infrastructure Requirements to Perform Standard, Intermediate, or Complex Surgical Procedures, May 6, 2010.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The System Director reviews the timeliness of specialty care consults and ensures that specialty consults are provided timely as required by Veterans Health Administration policy, including the use of service/care coordination agreements as necessary to define time frames.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The System Director ensures the Facility provides a list to the Emergency Department and inpatient staff of appropriate on-call social work and mental health staff, as well as specialty physicians, including radiologists, as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/12/2019
The System Director ensures the Facility provides and monitors the availability and timely response of specialty consultants and ultrasound services in the Emergency Department as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages FY 2018
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18-01693-196
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Topics:  Staffing

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
The Under Secretary for Health refines and formalizes VHA’s position categorization of individuals (clinical and nonclinical) who are necessary to VHA’s mission of delivering health care by looking at various dimensions of each occupation, including staff skill set and function, enabling identification of positions based on the specific role a person would fill.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/28/2019
The Under Secretary for Health ensures the consistent implementation and use of the position categorization approach across all facilities.
Comprehensive Healthcare Inspection Program Review of the Phoenix VA Health Care System, Phoenix, Arizona
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18-00611-180

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
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. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Facility Director ensures all patient incidents are entered into WebSPOT and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Deputy Director and Associate Director ensure personal protective equipment is readily accessible and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Associate Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Associate Director requires Nutrition and Food Service managers ensure garbage receptacles are stored separately from food preparation areas and properly covered with tight-fitting lids and monitors managers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Associate Director requires Nutrition and Food Services managers ensure all food items are properly labeled with expiration dates, as appropriate, and monitors managers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Associate Director requires Nutrition and Food Services managers ensure temperature monitoring occurs in the dry food storage area and monitors managers’ compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Facility Director ensures that Controlled Substances Inspectors complete routine monthly controlled substances inspections and monitors compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Facility Director ensures that controlled substances inspections are randomly performed to ensure the element of surprise and monitors compliance.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/7/2019
The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
The Chief of Staff ensures that geriatric evaluation providers complete a medical evaluation of patients admitted to the program and monitors providers’ compliance.
Colorectal Cancer Screening, Timely Colonoscopies, and Physician Coverage in the Intensive Care Unit at the James H. Quillen VA Medical Center, Mountain Home, Tennessee
|
16-02940-183

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
The Veterans Integrated Service Network 9 Director ensures that clinical reviews are completed on the patients discussed in this report to determine whether delays adversely affected patients’ clinical care, notifies patients of lapses in care as needed, and/or takes other action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track and recall patients who require surveillance colonoscopies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track patients for whom a diagnostic colonoscopy after a positive fecal immunochemical test is indicated as required by Veterans Health Administration and James H. Quillen VA Medical Center policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director improves efforts to ensure non-VA colonoscopy reports are available for viewing in patients’ VA electronic health records.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director ensures that processes are in place to monitor providers’ compliance with Veterans Health Administration Colorectal Cancer Screening policy including the referral of the patient for a diagnostic colonoscopy after a positive fecal immunochemical test rather than a repeat fecal immunochemical test.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/26/2018
The James H. Quillen VA Medical Center Director takes action to identify patients who submitted fecal immunochemical test kits that could not be processed and notifies these patients of a need to re-submit fecal immunochemical test specimens.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2019
The James H. Quillen VA Medical Center Director ensures that processes are strengthened to track and monitor the distribution of fecal immunochemical test kits to patients.
Comprehensive Healthcare Inspection Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio
|
17-05398-172

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2018
The Facility Director ensures all patient incidents are entered into the VHA Patient Safety Information System and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2019
The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2019
The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 7/2/2019
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/15/2018
The Associate Director ensures bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2018
The Director ensures that the Alternate Control Substance Coordinator’s position description or functional statement includes an addendum for the Control Substance Coordinator’s duties and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/17/2018
The Director ensures that all Controlled Substance Inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina
|
18-00412-173

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Chief of Staff ensures Service Chiefs complete required elements of Focused Professional Practice Evaluations for review by the Medical Executive Board and monitors compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Chief of Staff ensures that Service Chiefs include all required elements for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures all required team members consistently participate on environment of care rounds and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Associate Director ensures that Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Associate Director ensures all medical equipment is identified as safe for patient use and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Chief of Staff ensures providers complete suicide risk assessments, within the required timeframe, for patients with positive Post-Traumatic Stress Disorder screens and monitors providers’ compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Chief of Staff ensures that geriatric evaluation program performance improvement activities are presented to an appropriate leadership board and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/25/2018
The Chief of Staff ensures that clinicians accurately identify and implement the Geriatric Evaluation plan of care interventions and monitors compliance.
Comprehensive Healthcare Inspection Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada
|
18-00605-174

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Facility Director requires the Patient Safety Manager to ensure completion of the required minimum of eight root cause analyses each fiscal year and monitors the Patient Safety Manager’s compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2019
The Chief of Staff ensures that service chiefs include service-specific performance data for Ongoing Professional Practice Evaluations and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Associate Director requires the Nutrition and Food Services Chief to develop and implement a Hazard Analysis Critical Control Point Food Safety plan and monitors the Chief’s compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director requires the Nutrition and Food Services Chief to establish a food service-focused inspection process to occur at no less than quarterly intervals and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/10/2019
The Associate Director requires the Nutrition and Food Services Chief to ensure that food items are properly labeled and monitors compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2019
The Chief of Staff ensures that providers complete suicide risk assessments, within the required timeframe, for patients with positive post-traumatic stress disorder screens and monitors the providers’ compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/21/2018
The Associate Director for Patient Care Services ensures that nursing staff involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors staff compliance.
VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2017
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17-05460-169

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/7/2020
The Executive in Charge, Office of the Under Secretary for Health, develops a timeline to reduce improper payments under the 10 percent threshold for the Beneficiary Travel; Communications, Utilities, and Other Rents; Medical Care Contracts and Agreements; Prosthetics; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding and recommendation for the Purchased Long Term Services and Support and VA Community Care programs from our FY 2015 and 2016 reports.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/14/2020
The Executive in Charge, Office of the Under Secretary for Health, implements steps to achieve stated reduction targets for the Beneficiary Travel; Civilian Health and Medical Program of the Department of Veterans Affairs; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding for all five programs from our FY 2016 report.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/14/2020
The Executive in Charge, Veterans Benefits Administration, implements steps to achieve reduction targets for the Pension and Post-9/11 GI Bill Programs.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/16/2019
The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, implement procedures to ensure thorough testing of sample items used to estimate improper payments for Supplies and Materials purchases under indefinite delivery contracts.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/7/2020
The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly. This is a repeat recommendation from our FY 2016 report.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/22/2020
The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue to report statutory barriers preventing complete resolution of drill pay improper payments in future Agency Financial Reports until resolved.
Comprehensive Healthcare Inspection Program Review of the VA Puget Sound Health Care System, Seattle, Washington
|
18-00334-164

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2018
The Deputy Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Deputy Director ensures all medical equipment at the South Sound VA Clinic is identified as safe for patient use and monitors compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Chief of Staff ensures the Infection Control Committee consistently documents discussions of on-going construction activities and monitors compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/24/2018
The Assistant Director ensures temperature monitoring occurs in dry food storage areas and monitors compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/28/2018
The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
Audit of the Beneficiary Travel Program, Special Mode of Transportation, Eligibility and Payment Controls
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15-00022-139

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure clinicians and Beneficiary Travel Office staff comply with Veterans Health Procedure Guide 1601B.05 eligibility requirements for authorizing Special Mode of Transportation services.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health modify Veterans Health Administration Procedure Guide 1601B.05 to require the Beneficiary Travel Office staff to verify beneficiaries attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure VA Medical Centers comply with Veterans Health Administration policies for verifying beneficiaries listed on vendor invoices had been properly authorized for Special Mode of Transportation services or attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health ensure the Improper Payments Elimination and Recovery Act reports provided to Veterans Integrated Service Networks are modified to include Special Mode of Transportation information specific to vendor payments by VA Medical Centers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/22/2023
The OIG recommended the Under Secretary for Health implement use of Centers for Medicare and Medicaid Services Rates when savings can be achieved for Special Mode of Transportation ambulance services in accordance with 38 U.S.C. Section 111(b)(3)(C).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/27/2019
The OIG recommended the Under Secretary for Health implement controls to prevent beneficiaries using Special Mode of Transportation services from also obtaining mileage reimbursement for the same appointment(s).
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 173,829,000.00
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