All Reports

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.
Audit of VA's Compliance With the DATA Act
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17-02811-21

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer continue progress with system modernization efforts. Ensure that current and upcoming DATA Act requirements are incorporated so that the detail level requirements for meeting the DATA Act will be made possible as automatic bulk file transmissions going forward.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer establish milestones to monitor VA's system modernization efforts. Coordination with the shared service provider should continue to incorporate current and upcoming DATA Act requirements to ensure that they will be met going forward.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer obtain procurement management system and if feasible, grants management system capabilities that are integrated with the financial system as part of VA's transition to a shared service provider.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer to the extent possible, reduce the amount of journal vouchers to those related to accrual adjustments or one time, unusual Adjusted Trial Balance System (GTAS) trial balance and resolve variances between the two systems. transactions. Journal vouchers recorded should contain data elements required for File B such as the program activity. In addition, if possible, automate efforts to combine FMS journal output files with the MinX-based Governmentwide Treasury Account Symbol
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer reduce the extensive use of 1358 obligations, and develop an automated procurement action capturing and reporting mechanism to timely capture all procurement activities greater than $3,500 for the File D1 submission.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer prepare the SBR and ensure reconciliation of File A, SF-133s and the SBR prior to File A submission.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer continue efforts to reduce the number of journal vouchers to those related to accrual adjustments or one time, unusual transactions. Journal vouchers recorded should contain data elements required for File B such as the program activity code and budget object class. In addition, if feasible, automate efforts to combine FMS journal output files with the MinX-based GTAS trial balance and identify and resolve variances between the two systems.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer where feasible, perform validation of MinX journal vouchers as they may contain errors and reside in the ultimate File B submission.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer research and resolve warnings identified by the broker before DATA Act files submission.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure that knowledge of DATA Act processes is not limited to one or a few people, and develop a succession plan to ensure the required expertise and capabilities will continue to remain available before personnel with highly technical and specialized knowledge leave or retire from the agency.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure complete reconciliations between the subsidiary and general ledger systems are performed. Differences should be researched and resolved to improve data accuracy, completeness and quality.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer for all TASes, ensure that amounts can be distinguished between general ledger accounts 4901 and 4902.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure a timely reconciliation process between File A and File B; File B to File C (when applicable); and File B to Files D1 and D2 such that procedures are completed prior to certifying each quarter¿s submission through the broker. Research and resolve variances identified through reconciliation processes.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer maintain documentation to support the various cost allocation methodologies used for aggregating VHA transactions included in File D2. Ensure File D2 VHA aggregated data includes only the required costs for DATA Act submission. Seek formal confirmation from OMB and Treasury that the direct services VHA is reporting should be included in File D2 as financial assistance awards and the employee payroll and File D1 duplicate contract cost data VHA is reporting should or should not be included in File D2 as financial assistance awards
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer provide targeted training to address specific issues identified to DATA Act points of contact on USASpending.gov requirements.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer implement PMO oversight of the reports submitted by VBA and VHA's ARC to ensure completeness, timeliness, quality, and accuracy of the information reported.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer implement internal controls related to the proper tracking and accounting for intragovernmental transfers as to their trading partner, type, and nature. Produce reliable subsidiary reports with transfer level details to facilitate management¿s reconciliation and reporting with the trading partner. Any differences between File A and B should be researched and corrected prior to file submission.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer research and identify the root cause of those transactions with default program activity names and implement corrective actions to address those issues. In addition, implement FMS and MinX JV edit checks to ensure all JVs contain the proper program activity name, program activity code and object class code or the JV will not be accepted by the system. The JV reviewer should ensure all those elements are properly recorded and are consistent with OMB A-11 and the President's Budget to improve the accuracy of the data.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer assess the impact of the internal control weaknesses reported and develop corrective actions to address data quality issues at the individual or aggregate transaction level.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure the complete reporting of all required data elements. Establish and develop a process to validate data quality for all DATA Act files on a regular basis prior to file submission
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Office of Management (OM)
Closure Date: 11/8/2019
We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer continue to maintain communication with OMB and Treasury regarding VA¿s data reporting limitations and progress, and document such communication.
Healthcare Inspection – Patient Death Following Failure to Attempt Resuscitation, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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17-01208-07

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires staff to immediately verify resuscitation status without delaying resuscitative efforts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers update the Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation policies to align with one another and include specific processes and responsibilities for determining resuscitation status, including at the time of a Nurse Led Rapid Response.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers educate staff on telemetry policy, align clinical practice with policy, educate staff on this policy and practice, and monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers obtain an independent external review of this patient’s medical care.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director consider taking appropriate administrative action for all involved clinicians, including consideration of the reporting requirements to applicable state licensing board(s).
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/21/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers review electronic health record documentation of resident supervision, medical decision-making, and resident physician to attending physician discussion of care during an emergency situation and monitor compliance.
Healthcare Inspection – Evaluation of System-Wide Clinical, Supervisory, and Administrative Practices, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma
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16-02676-13

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the Veterans Integrated Service Network Director review the former Chief of Surgery’s performance in relation to issues discussed in this report, and confer with appropriate VA offices to determine the need for administrative action, if any.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended the System Director consult with the National Center for Organizational Development to facilitate organizational improvement following leadership changes and extensive inspections and investigations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure use of the correct methodology to determine the severity assessment code for all reported patient safety events.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure compliance with the National Center for Patient Safety’s guidelines on initiation and completion of Root Cause Analysis.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure that peer reviews are appropriately completed and address all relevant aspects of care provided by the reviewed clinician.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure a process is in place to identify and review cases where institutional disclosure may be indicated, and complete as appropriate.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended the System Director ensure that the Quality, Safety and Value committee minutes include evidence of robust data analysis and action tracking to address performance deficiencies, and monitor for compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure adherence to all Veterans Health Administration peer review committee requirements, and monitor for compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure that professional practice evaluations include performance data to support provider privileges and are conducted in accordance with Veterans Health Administration and System policy.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director evaluate the current System policy and services provided by low volume/no volume providers to determine whether the System should continue to provide those services or seek community alternatives.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director require service chiefs to assure that all providers within their purview secure and maintain appropriate computer access to ensure quality and continuity of patient care.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/12/2018
We recommended that the System Director ensure availability of functional equipment, adequate staffing, and enhanced access for personal identity verification card completion.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure compliance in monitoring of resident supervision documentation in accordance with Veterans Health Administration and System policies, and take appropriate action when deficiencies are identified.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director review letters of agreement between the University of Oklahoma’s surgical residency program and the System to ensure compliance with Accreditation Council for Graduate Medical Education requirements.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director continue efforts to recruit and hire for vacancies, and ensure that, until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure timely completion of specialty care consults and monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director implement a process to conduct routine scheduling audits to monitor compliance and identify ongoing training opportunities for all schedulers.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director conduct an evaluation of the potential improper payments resulting from clinic cancellations, take appropriate corrective actions, and establish policies to mitigate improper payments related to clinic cancellations from occurring in the future.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director continue efforts to improve call center timeliness.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director continue efforts to improve timeliness of Care in the Community Program consult completion; enhance patient and community provider understanding of Veterans Choice and Non-VA Care Coordination options; and continue to promote communication and coordination with TriWest Healthcare Alliance to assure appropriate, timely care for patients.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director ensure Patient Aligned Care Team clinicians follow Veteran Health Administration requirements for patient notification and follow-up of clinically relevant abnormal laboratory results and document the actions in the electronic health record.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director monitor consultation completion timeliness and identify process improvements for consults exceeding 30 days.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director continue Emergency Department workgroup efforts to improve the timeliness of care, decrease the frequency of diversion status, and enhance customer service in the Emergency Department.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director ensure that all patient care areas comply with environment of care requirements and that action plans specifically address deficient areas identified in this report.
Healthcare Inspection – Administrative and Clinical Concerns, Central California VA Health Care System, Fresno, California
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16-00352-12

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that System leaders establish written protocols to identify a process to transfer Emergency Department boarded patients to available VA and non-VA facilities when acute inpatient beds are unavailable.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that the policy that designates the location for Emergency Department patient overflow includes criteria for boarded patients who can be placed in the community living center.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that a policy is developed and implemented to ensure that Emergency Department staff offer boarded patients transfer to a VA or non-VA facility for inpatient care and that Emergency Department staff document the offers and managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director ensure that managers continue to strengthen processes to improve boarded patients’ length of stay in the Emergency Department.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that Emergency Department providers reassess patients prior to transfer to confirm that patients are stabilized and suitable for transfer to the receiving unit.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director implement applicable recommendations from previous patient event-related reviews and monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director consult with the Office of Chief Counsel regarding whether an institutional disclosure might be appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director consider requesting an external administrative review to determine whether the system was adequately prepared to safely manage its patient volume.
Audit of VBA’s National Pension Call Center
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16-03922-392

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2018
We recommended the Acting Under Secretary for Benefits ensure National Pension Call Center management implements controls to require supervisors to review and take corrective actions for inaccuracies identified when evaluating calls.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/6/2019
We recommended the Acting Under Secretary for Benefits ensure Benefits Assistance Service has qualified staff to evaluate the quality of Spanish-speaking calls received at the National Pension Call Center.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2018
We recommended the Acting Under Secretary for Benefits ensure National Pension Call Center and Benefits Assistance Service management implement controls to help ensure staff complies with all training requirements identified in Benefits Assistance Service National Training Curriculum.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2018
We recommended the Acting Under Secretary for Benefits ensure National Pension Call Center management implements controls to ensure staff completes course evaluations or assessments for instructor-led training in the Talent Management System to record training hours timely.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 6/13/2018
We recommended the Acting Under Secretary for Benefits continuously evaluate the NPCC Cisco data and determine if a plan is needed to modify operating hours to accommodate callers, including those residing outside the Eastern Time Zone.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 1/15/2019
We recommended the Philadelphia VA Regional Director strengthen controls at Philadelphia VA regional office to help ensure correspondence that may include personally identifiable information is mailed to the intended veteran.
Review of Claims Processing Actions at Pension Management Centers
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15-04156-352

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/1/2017
We recommended the Acting Under Secretary for Benefits clarify the guidance for VA general medical examinations requirements related to original pension claims.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/30/2018
We recommended the Acting Under Secretary for Benefits ensure staff at the Pension Management Centers receive training based on the clarified guidance for VA medical general examination requirements related to original pension claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/21/2018
We recommended the Acting Under Secretary for Benefits ensure St. Paul claims processing staff review the 605 pension claims denied without a VA general medical examination in CY 2015 to determine whether corrective action is necessary based on clarified guidance and report to the OIG the number of denials reversed.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/3/2018
We recommended the Acting Under Secretary for Benefits develop and implement a plan to ensure rating consistency across Pension Management Centers.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 11/1/2017
We recommended the Acting Under Secretary for Benefits implement a plan to ensure claims processing staff prioritize actions for cases involving benefits reductions based on Medicaid-covered nursing home care to minimize improper payments.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/21/2018
We recommended the Acting Under Secretary for Benefits develop workload performance measures for cases involving benefits reductions based on Medicaid-covered nursing home care to minimize improper payments.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/30/2018
We recommended the Acting Under Secretary for Benefits develop and implement training for claims processing staff that is specific to Medicaid-covered nursing home cases.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 41,400,000.00
Review of Potential Misuse of Purchase Cards at Veterans Integrated Service Network 15
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15-05519-377

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/24/2018
We recommended the Veterans Integrated Service Network 15 Director submit ratification requests for the fiscal year 2015 unauthorized commitments identified in our report to the Veterans Health Administration’s Head of Contracting Activity.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/19/2018
We recommended the Veterans Integrated Service Network 15 Director, in coordination with the Network Contracting Office Director, conduct additional focused training for its purchase cardholders and approving officials on what constitutes splitting purchases and how to avoid them.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
We recommended the Veterans Integrated Service Network 15 Director, in coordination with the Network Contracting Office Director, establish more rigorous monitoring mechanisms to identify improper purchase card transactions.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 73,000.00
Healthcare Inspection – Opioid Agonist Treatment Program Concerns VA Maryland Health Care System Baltimore, Maryland
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16-01091-06

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/22/2018
We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program counselors provide treatment planning consistent with Title 42 of the Code of Federal Regulations Part 8, Substance Abuse and Mental Health Services Administration guidelines, and local policy requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program counselors provide counseling sessions consistent with Title 42 of the Code of Federal Regulations Part 8, Substance Abuse and Mental Health Services Administration guidelines, and local policy requirements.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program leaders consider implementing clear policies regarding the management of cardiac risk that include annual electrocardiographic assessment consistent with Substance Abuse and Mental Health Services Administration guidelines.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure Opioid Agonist Treatment Program administrative policies assign regulatory compliance responsibilities consistent with Title 42 of the Code of Federal Regulations Part 8 and Substance Abuse and Mental Health Services Administration guidelines.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure that the Baltimore VA Medical Center Opioid Agonist Treatment Program Medical Director is present at the program a sufficient number of hours to ensure regulatory compliance consistent with Title 42 of the Code of Federal Regulations Part 8 and Substance Abuse and Mental Health Services Administration guidelines.
Audit of Purchase Card Use To Procure Prosthetics
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15-04929-351

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended the Acting Under Secretary for Health require Prosthetic and Sensory Aids Service conduct periodic analyses of Veterans Health Administration prosthetic purchases to identify commonly used prosthetics that offer opportunities for VA’s Strategic Acquisition Center to leverage Veterans Health Administration’s purchasing power by pursuing Veterans Health Administration-wide or multi-Veterans Integrated Service Network contracts.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2018
We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office and Prosthetics and Sensory Aids Service to periodically monitor prosthetic procurements to ensure Veterans Integrated Service Networks and Network Contracting Offices identify and report prosthetics usage and cost data for use in developing Veterans Integrated Service Network contracts when Veterans Health Administration wide or multi-Veterans Integrated Service Network contracts are not possible.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2018
We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office to review fiscal years 2015 and 2016 prosthetic purchase card transactions above the micro-purchase limit and submit identified unauthorized commitments to Heads of Contracting Activities for ratification actions.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2018
We recommended the Acting Under Secretary for Health direct Heads of Contracting Activities to perform ratification actions for unauthorized commitments identified by the Procurement & Logistics Office review of fiscal years 2015 and 2016 prosthetic purchase card transactions above the micro-purchase limit and consider holding cardholders and their approving officials accountable for unauthorized commitments, as appropriate.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/24/2018
We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office to develop a process for conducting periodic reviews to evaluate compliance with the requirements of VHA Directive 1081, VA Procurement Policy Memorandum 2016-02, and the Veterans Health Administration’s Memorandum, Implementation of the Implant Pre-authorization Process.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,120,699,904.00
Clinical Assessment Program Review of the VA Eastern Colorado Health Care System, Denver, Colorado
|
16-00546-388

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility ensure the designated quality, safety, and value committee meets quarterly and is chaired or co-chaired by the Facility Director.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility revise the policy/by-laws to specify a frequency for clinical managers to review practitioners’ Ongoing Professional Practice Evaluation data every 6 months.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/11/2019
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that the facility consistently evaluate actions for effectiveness in the Clinical Executive Committee and Performance Improvement Board and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
We recommended that facility managers ensure horizontal surfaces, ventilation grills, and floors in patient care areas are clean and monitor compliance.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that facility managers ensure the standard operating procedure for the retrograde cholangiopancreatography endoscope is consistent with the manufacturer’s instructions for use.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive competencies at orientation and annually for the types of reusable medical equipment they reprocess.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility revise the policy for anticoagulation management to include addressing no shows and patient noncompliance and minimizing loss to follow-up.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that clinical managers complete semiannual competency assessments for employees actively involved in the anticoagulant program and that facility managers monitor compliance.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 16
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/18/2019
We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in transfer documentation and that facility managers monitor compliance.
No. 17
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
We recommended that facility managers ensure that for emergent transfers, provider transfer notes include patient stability for transfer and monitor compliance.
No. 18
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.
No. 19
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/20/2019
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 20
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
We recommended that the facility report and trend the use of reversal agents in moderate sedation cases and process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.
No. 21
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the VA Police Officer, Patient Safety Manager and/or Risk Manager, and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 22
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
We recommended that the facility collect and analyze data from disruptive or violent behavior incidents.
No. 23
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
No. 24
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 25
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2020
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 26
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/14/2018
We recommended that all doors on the Domiciliary Care for Homeless Veterans Program unit other than the main point of entry be locked and alarmed.
No. 27
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility fully implement the nurse staffing methodology and conduct annual reassessments.
Inspection of VA Regional Office Anchorage, Alaska
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17-02084-343

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2017
We recommended the Anchorage VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Anchorage VA Regional Office Director strengthen oversight to ensure data input at the time of claims establishment is reviewed for accuracy.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2017
We recommended the Anchorage VA Regional Office Director implement a plan to monitor the effectiveness of training related to claims establishment procedures.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Anchorage VA Regional Office Director provide training for designated congressional liaison staff who process special controlled correspondence and monitor the effectiveness of the training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Anchorage VA Regional Office Director implement a plan to ensure oversight is strengthened for special controlled correspondence.
Review of Alleged Adverse Effect on Patient Care Due to Removal of a Computer-Assisted Survey Instrument
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16-00838-348

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/29/2017
We recommended the Acting Assistant Secretary for Information and Technology implement appropriate controls to ensure that Class III software is not installed on VA networks without a formal technical review and authority to operate, and that training is provided to OIT Region 1 staff on the treatment of Class III software.
Review of Alleged Use of Wrong VA Funds To Purchase IT Equipment
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16-00753-338

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended the Veterans Integrated Service Network 23 Director consult with VA’s Office of General Counsel and take necessary corrective actions to correct the funding error related to the purchase of WiFi and cable television services and ensure that appropriate funds are used for future information technology purchases in accordance with VA policy and VA’s Office of General Counsel guidance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended the Veterans Integrated Service Network 23 Director work with the Chief Financial Officer to determine if an Antideficiency Act violation occurred and take action as deemed appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 2/5/2018
We recommended the Acting Assistant Secretary for Information and Technology update the 2016 IT/Non-IT Policy to address the dissemination of decisions and issues that may be systemic across VA.
Review of Alleged Payment Issues at Kerrville VA Hospital Kerrville, Texas
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16-02151-320

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2018
We recommended the director of the STVHCS instruct PRMC to stop advising veterans that they may be liable for pre-authorized NVC.
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