All Reports

The OIG recommends executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.

The OIG recommends executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.

The OIG recommends executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.

The OIG recommends executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.

The OIG recommends executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.

The OIG recommends executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patient’s care.

The OIG recommends Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.

The OIG recommends executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.

Seek the opinion of the Office of General Counsel on whether the identified potential overbillings could or should be recouped.

As a part of the annual certification process of the Capital Asset Inventory, the executive director of the Office of Asset Enterprise Management should provide guidance on underground storage tank entries to ensure these assets are recorded with consistent identifying terminology in asset identification fields and with the appropriate real property predominant use code: code 40, “storage (other than buildings).”

Ensure Veterans Integrated Service Network officials fulfill their oversight responsibilities found in Veterans Health Administration Directive 1811 requiring VA medical facilities maintain a current inventory of underground storage tanks, inclusive of all associated equipment and component levels.

Ensure the assistant under secretary for health for support updates the responsibility section in Veterans Health Administration Directive 7707 to ensure that the responsibilities of VA medical facility directors include appropriate designation of staff and training for environmental regulatory requirements.

Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 to ensure facility compliance with federal, state, and local codes, laws, and regulations—including monitoring and addressing underground storage tank alarms promptly to confirm a release has not occurred.

Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 for work order (unplanned corrective maintenance) tracking from creation through completion in the approved maintenance management system—to include underground storage tank and associated component-level equipment failures or deficiencies identified in regulatory agencies’ inspections.

Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling responsibilities in Veterans Health Administration Directive 7707 to ensure regulatory compliance deficiencies are promptly reviewed, corrective actions are developed, and issues are tracked through completion to satisfactorily address environmental compliance.

Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling their oversight responsibilities found in Veterans Health Administration Directive 7707 to ensure all required federal, state, and local regulatory agencies’ inspections of underground storage tanks are recorded in the Veterans Health Administration issue brief tracking system.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety between the parking garage and bed tower entrance until completion.

The OIG recommends facility leaders improve doorway safety at the bed tower entrance by placing sensors on the two power-assisted doors, reactivating the revolving door, and monitoring doorway safety until completion.

The OIG recommends the Director ensures staff monitor the emergency exit near the laboratory to make sure the door remains unlocked and operational.

The OIG recommends the Director assesses the facility’s tactile signs (braille) and auditory cues and implements a plan to address the deficient areas.

The OIG recommends facility leaders evaluate the toxic exposure screening process and implement a plan to ensure staff complete the screenings.

The Under Secretary for Health clarifies Veterans Integrated Service Network staffing requirements, including mandatory and discretionary positions.

The Under Secretary for Health ensures the use of the standardized Veterans Integrated Service Network core organizational chart to promote clarity of the Chief Mental Health Officer position and reporting structure.

The Under Secretary for Health considers standardization of the Veterans Integrated Service Network Chief Mental Health Officer functional statement to reflect role responsibilities.

The Under Secretary for Health ensures the alignment of the Veterans Integrated Service Network Chief Mental Health Officer performance plan with the functional statement.

The Under Secretary for Health defines the Veterans Integrated Service Network Chief Mental Health Officer role authority to enhance governance efficiency and effectiveness of mental health services.

Develop comprehensive management controls with clear roles and responsibilities at each level of the Veterans Benefits Administration to ensure effective oversight of mandatory accounts and the timely communication of any potential budgetary shortfalls.

Ensure the Office of Financial Management develops procedures to incorporate all available budgetary resources, as reported on the SF-133s, in its calculations for the status of funds reports for transparent communication to internal and external stakeholders.

Institutionalize monthly fiscal reviews between the Office of Financial Management and program offices to routinely assess performance and cost drivers that may affect the status of available funds.

Institutionalize monthly fiscal reviews between the VA Office of Budget and the Veterans Benefits Administration Office of Financial Management to routinely assess performance and cost drivers that may affect the status of available funds.

Review the Veterans Health Administration’s current methods, assumptions, and approaches used to project medical care budget needs in the annual President’s Budget to identify any gaps in the process or data limitations, and develop and implement a plan to strengthen the process.

Establish and implement a plan to review current processes and procedures for involving program offices and pertinent subject matter experts in developing the Enrollee Health Care Projection Model inputs for specific areas such as community care, staffing, pharmacy services, and prosthetics services, and formalize the expectations of their involvement in this process through guidance or protocols.

Develop and implement an approach to estimate medical care personnel needs and costs to increase the accuracy and reliability of information included in the annual President’s Budget.

Institutionalize a regular cycle of at least quarterly fiscal reviews among assistant under secretaries for health, network directors, and program offices that routinely assess key cost drivers and other areas of concern, such as staffing, community care growth, and local initiatives.

The Hampton VA Medical Center Director directs nursing leaders to review records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders to confirm that medical intensive care unit nurses document Clinical Institute Withdrawal Assessment of Alcohol Scale scores consistent with patient’s documented behavior and symptoms and takes actions to address any deficiencies that are identified.

The Hampton VA Medical Center Director confirms that nursing leaders complete review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders to determine the extent with which administration of medication is in adherence with the protocol and take actions to address any deficiencies that are identified.

The Hampton VA Medical Center Director ensures that a review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders is completed by nursing leaders to (a) assess the degree of compliance with completing Clinical Institute Withdrawal Assessment of Alcohol Scale assessments based on the last assessment score, as outlined in the protocol, and (b) review the actual time Clinical Institute Withdrawal Assessment of Alcohol Scale is completed in comparison to the time it is documented in the electronic health records to identify significant delays, if any, and based on analysis of findings, takes action to address deficiencies that are identified.

The Hampton VA Medical Center Director works with the facility Chief of Staff to ensure medical intensive care unit providers have reviewed a clinical practice guideline specific to management of alcohol withdrawal from an accredited source, such as The American Society of Addiction Medicine.

The Hampton VA Medical Center Director confirms completion of a review to assess the current process for communicating unit-based medication shortages and how staff can confirm the availability of shortage medications when use of the medication is key to the patient’s treatment and updates the process as warranted.

The Hampton VA Medical Center Director ensures that the facility’s Alcohol Withdrawal Management standard operating procedure aligns with requirements for a standard operating procedure outlined in Veterans Health Administration Notice 2024-09.

The Hampton VA Medical Center Director confirms that training requirements specified in Veterans Health Administration Notice 2024-09 are completed, training attendance is tracked, and a process is in place to monitor accurate and consistent use of the alcohol withdrawal scale identified in the facility standard operating procedure.

The OIG recommends the Director evaluates accessible parking spaces at the circle of the main entrance and ensures access aisles have visible pavement markings and remain available for use.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalks until completion.

The OIG recommends facility leaders improve doorway safety at the main entrance.

The OIG recommends the Director ensures staff have adequate hand hygiene supplies in or near soiled utility rooms that contain biohazardous materials.

The OIG recommends facility leaders ensure the facility policy for communication of test results and service-level workflows comply with VHA requirements, and staff implement processes to monitor patient notification of test results.

The OIG recommends facility leaders increase hiring efforts for the vacant social work positions in the Housing and Urban Development–Veterans Affairs Supportive Housing program, and in the interim, provide staff to support program enrollment.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care oversight councils function according to their charters and meet the required number of times per fiscal year.

The Veterans Integrated Service Network Director, in conjunction with facility directors, reassess community care staffing needs and act as necessary.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility staff import all community care documents into the patient’s electronic health record within five business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment after administratively closing consults that are not low risk.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their community care appointments.

The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in the patient’s electronic health record when they receive medical documentation from the community provider.

Evaluate its Veteran Self-Scheduling training and identify improvements if they are needed.

Make certain that staff who are involved in the Veteran Self-Scheduling process are trained on how to assess eligibility for the scheduling option, communicate key information to veterans on the option, and conduct appropriate consult follow-up procedures.

Ensure all guidance related to the Veteran Self-Scheduling process is clear, consistent, and disseminated to all VA medical facilities.

Establish a mechanism to effectively track and monitor each VA medical facility’s challenges with implementation of the Veteran Self-Scheduling process and then develop a plan to address reported issues.

Develop best practices and lessons learned for implementing the Veteran Self‑Scheduling process and disseminate them to all VA medical facilities.

Develop controls to ensure VA medical facility staff have the tools in place to identify instances of potential inappropriate processing or inappropriate use of Veteran Self-Scheduling consults.

Direct facilities to conduct routine reviews of Veteran Self-Scheduling consults to identify potential inappropriate processing or use of the Veteran Self-Scheduling option and notify VHA’s Office of Integrated Veteran Care of instances of inappropriate use.

Develop a plan to accurately assess whether the Veteran Self‑Scheduling process is meeting its intended goals.

The Montana VA Healthcare System Director assesses the timeliness of appointment setting for direct and community care referrals and ensures facility staff establish appointments within required time frames.

The Montana VA Healthcare System Director assesses the timeliness of completion of community care appointments within 90 days of requested date and acts on identified opportunities for improvement.

The Montana VA Healthcare System Director reviews consult management practices and ensures receiving staff document scheduled appointment dates for VA direct care referrals.

The Montana VA Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.

The Montana VA Healthcare System Director ensures community care providers utilized by the system are designated as eligible in the Provider Profile Management System and acts on identified opportunities to improve the accuracy of eligibility designations.

Ensure supervisors conduct monitoring activities, including periodic reviews of expendable and nonexpendable inventory and root cause analyses of identified discrepancies to strengthen controls over VA supplies.

Establish routine monitoring for the accountable officer to verify the required use of barcode labels to track and identify supplies and equipment and report deficiencies for barcode replacement.

Address all unaccepted equipment and establish a requirement for custodial officers to routinely accept equipment in Maximo.

Implement a mechanism for the accountable officer to routinely monitor and ensure service‑line staff who conduct physical inventory are designated in writing by the custodial officers and receive the appropriate nonexpendable inventory training annually.

Require the accountable officer and supply chain staff to verify and update the information in the Maximo system and create procedures to ensure all nonexpendable equipment is received through the warehouse, recorded in Maximo, delivered in a timely manner to the requesting service, and accepted by the custodial officer.

Address the physical security issues identified and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouse.

Ensure all biological and nonbiological implants are recorded in the approved inventory management system and are routinely reconciled with other systems used to manage implant expiration dates.

Develop controls to ensure implant program staff identify and create local agreements for existing consignment implants and establish agreements for future consignment implants in accordance with national guidance.

Officially designate a facility implant coordinator and establish a monitoring mechanism to ensure compliance with implant coordinator roles and responsibilities.

Update the local implant management policy to clarify roles and responsibilities and to train staff in these roles about their implant management responsibilities.

The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalk between the patient parking garage and main entrance until completion.

The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.

The OIG recommends facility leaders implement actions to correct the electrical issue in the Emergency Department Main 2 area and mitigate the risk until it is resolved.

The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.

The Carl Vinson VA Medical Center Director ensures applicable staff, such as Sterile Processing Services staff and end users of reusable medical devices, comply with procedures regarding the identification of and disposition of nonconforming surgical instruments.

The Carl Vinson VA Medical Center Director confirms operating room staff completes training regarding the recognition of and procedures for nonconforming surgical instruments.

The VA Southeast Network Director establishes a comprehensive strategy to review patients who may have been affected by the approximately 800 nonconforming surgical instruments to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of disclosures.

The VA Southeast Network Director evaluates whether administrative action is warranted for employees regarding Sterile Processing Services deficiencies at the Carl Vinson VA Medical Center, and takes action as appropriate.

The VA Southeast Network Director provides consultation and oversight to the Carl Vinson VA Medical Center’s Sterile Processing Services to ensure implementation of facility-level action plans and sustainability of identified outcomes.

The OIG recommends that facility leaders review and correct any outdated navigational signage.

The OIG recommends facility leaders define and assign roles and responsibilities to toxic exposure screening navigators and ensure program oversight.

The OIG recommends the Director ensures staff keep patient care areas safe and clean.

The OIG recommends the Director ensures biohazard storage areas display proper signage, have appropriate hand-washing supplies and equipment available, and do not contain housekeeping supplies.

The OIG recommends the Associate Director ensures staff identify one or more facility environment of care trends and establish a performance improvement plan, including outcome measures, to address them.

The OIG recommends that facility leaders continue to develop and implement administrative processes to ensure ordering providers promptly communicate and document test results.

The OIG recommends that facility leaders ensure staff maintain and reference current VHA requirements and update facility-level policies and standard operating procedures to comply with them.

The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.

The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.