All Reports

Healthcare Inspection - Alleged Inappropriate Opioid Prescribing Practices, Rutherford County Community Based Outpatient Clinic, Rutherfordton, North Carolina
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15-01982-113

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that primary care providers are able to assess, treat, monitor, and reassess patients on chronic opioid therapy within the appropriate timeframe.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that the Veterans¿ Integrated Pain Management Clinic meets non-opioid pain management needs of patients as evidenced by timely consultation completions.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director consider the clinical and administrative demands of chronic opioid therapy care when determining appropriateness of primary care provider staffing and that staffing plans are in place for planned and unplanned provider vacancies and absences.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that benzodiazepine appropriateness evaluations are completed as required for chronic opioid therapy patients with post-traumatic stress disorder.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that primary care and mental health providers communicate and coordinate care for post-traumatic stress disorder patients receiving both opioids and benzodiazepines.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure regular communication between facility leadership and community based outpatient clinic leadership to support consistent high quality care.
Healthcare Inspection – Operating Room Reusable Medical Equipment and Sterile Processing Service Concerns, VA New York Harbor Healthcare System, New York, New York
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14-04274-418

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director charter a team to evaluate the facility's entire process involving reusable medical equipment in accordance with applicable guidelines, integrate reviews' recommendations, and develop an overarching reusable medical equipment management plan.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable national and local policies and guidelines for the reprocessing of reusable medical equipment and the preparation of trays and instrument lists.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable guidelines to record daily temperature and humidity levels in Sterile Processing Service areas and act upon and document actions when temperature and humidity levels are out of range.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure that an ergonomic assessment be made of the physical access and weight of items stored in the operating room Sterile Processing Service storage area and ensure staff safety and compliance with applicable Occupational Safety and Health Administration standards.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure training of operating room staff in proper handling of sterile packages and establish a formal process to track and trend issues with packages.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure adequate staffing to manage the operational requirements of Sterile Processing Service.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure that the operating room and Sterile Processing Service staff implement a reusable medical equipment quality control program consistent with Veteran Health Administration guidelines.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director implement measures to improve collaboration and communication within and between operating room and Sterile Processing Service staff.
Review of VBA’s Special Monthly Compensation Housebound Benefits
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15-02707-277

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to prevent staff from completing a decision without considering potential eligibility to statutory housebound benefits any time a veteran has a single 100 percent evaluation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/27/2018
We recommended the then Acting Under Secretary for Benefits conduct a review of all veterans being paid compensation at the housebound rate with a combined evaluation of 90 percent or less and provide certification of completion of the review to the Office of Inspector General.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits establish a plan to conduct periodic reviews of high-risk cases in which housebound benefits are being paid.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits implement a plan to provide all decision-makers the updated special monthly compensation training and monitor the effectiveness of the training.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to ensure staff discontinue temporary housebound benefits when the criteria are no longer met.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/15/2017
We recommended the then Acting Under Secretary for Benefits remind staff of the requirements to use the Special Monthly Compensation Calculator in all special monthly compensation cases and include the results in the file, and implement a plan to ensure compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits clarify the meaning of the term substantially confined for housebound in-fact benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 154,400,000.00
OIG Determination of VHA Occupational Staffing Shortages
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16-00351-453
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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: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health ensure that the Veterans Health Administration develops staffing models for critical need occupations, and we further recommend that the Veterans Health Administration sets forth milestones and a timetable for further critical need occupations’ staffing model development, piloting, and implementation.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health review data on regrettable losses and consider implementing measures to reduce such losses.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health consider incorporating data that predicts changes in veteran demand for health care into its staffing model.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health assess the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.
Combined Assessment Program Summary Report – Evaluation of Advance Directives in Veterans Health Administration Facilities
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16-03960-428

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently ask inpatients whether they want to discuss advance directives and that facility managers monitor compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/8/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when inpatients request a discussion about advance directives, clinicians consistently document that the discussion occurred using only the two Veterans Health Administration standardized note titles for advance directive discussions and that facility managers monitor compliance.
Healthcare Inspection – Lack of Follow-Up Care for Positive Colorectal Cancer Screening, New Mexico VA Health Care System, Albuquerque, New Mexico
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15-00018-349

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2016
We recommended that the Facility Director ensure that all patients who experienced delays in notifications of positive fecal immunochemical tests are assessed to determine if appropriate follow-up care was rendered and whether the delays adversely affected the patients¿ clinical outcomes.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/27/2016
We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) regarding the care of the four patients described in this report and any additional patients identified in further review who may have been adversely affected, to determine the appropriate action to take, if any.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that the Facility Director ensure that providers communicate positive colorectal cancer screening results to patients and document notifications in electronic health records according to Veterans Health Administration test notification policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that the Facility Director ensure that processes are in place to monitor providers’ compliance with Veterans Health Administration colorectal cancer screening policy.
Review of VA’s Award of the PC3 Contracts
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15-01396-525

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 6/12/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure sufficient oversight on all high-dollar value and complex acquisitions to prevent violations of acquisition regulations and VA policies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 8/17/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure critical planning actions—requirements development, market research, and independent government cost estimates are performed and provided to contracting officers, prior to developing requests for proposals.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 6/12/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) obtain pricing analysis and technical assistance, to ensure quality products and services are procured at fair and reasonable contract prices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 6/12/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) enforce compliance with the VA policy to document all required acquisition decisions in the Electronic Contract Management System.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 16,800,000.00
Healthcare Inspection – Colorectal Cancer Screening Practices, Charlie Norwood VA Medical Center, Augusta, Georgia
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15-05328-373

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Facility Director ensure that the selection of a colorectalcancer screening method is based on a shared decision-making process between apatient and his/her provider and that the patient‘s preference is honored.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Facility Director define and communicate current localprocesses for obtaining screening colonoscopies.
Review of the Replacement of the Denver Medical Center, Eastern Colorado Health Care System
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15-03706-330

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/15/2017
We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction ensure required reconciliations of cost estimates be performed prior to releasing construction design documents for all major construction projects.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 7/31/2017
We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction provide sufficient, adequately trained and experienced staff to ensure appropriate oversight is provided over all phases for future major construction projects.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/21/2016
We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction establish policies and procedures to ensure disputes are resolved before proceeding with projects when actual cost and schedule milestones exceed established planned thresholds.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/21/2016
We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction implement mechanisms to ensure that adequate acquisition plans for major construction projects are completed at each appropriate acquisition stage.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 7/31/2017
We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction ensure adequate controls are implemented and monitored to verify change requests are processed timely.
Review of VA’s Alleged Improper Termination of the e Learning Task Order
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15-02776-240

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/19/2016
We recommended the Deputy Assistant Secretary for Acquisition and Logistics implement a mechanism to ensure proper coordination between the Veterans Affairs Acquisition Academy and Office of Logistics and Supply Chain Management when developing logistics training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 1,862,856.00
Review of Alleged Breach of Privacy and Confidentiality of Personally Identifiable Information at the Milwaukee VARO
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16-00623-306

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology improve VA’s email security filtering software configuration controls to effectively flag improper transmissions of veterans’ personally identifiable information over the VA network.
No. 2
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology establish Memoranda of Understandings with third party organizations that define network responsibilities, processes and procedures for handling sensitive veterans’ information, and require information security controls are implemented commensurate with VA’s information security standards.
No. 3
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology evaluate whether permanent encryption controls are needed for non-VA employees who maintain VA accounts for conducting business on behalf of veterans.
No. 4
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology conduct reviews of processes, procedures, and controls in place at VA regional offices that collaborate with third party organizations to ensure security of sensitive veterans’ information.
Healthcare Inspection – Emergency Department, Mental Health Service, and Suicide Prevention Training Concerns, Mann-Grandstaff VA Medical Center, Spokane, Washington
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15-03713-288

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/14/2016
We recommended that the Interim Facility Director strengthen processes to ensure suicide prevention training is completed per Veterans Health Administration Directive 1071 and monitor compliance.
Review of Alleged Contractor Information Security Violations in the Alaska VA Healthcare System
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15-01994-238

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2016
We recommended the VA Northwest Health Network management assign a local Contracting Officer¿s Representative and Information Security Officer to provide oversight of Alaska VA Healthcare System contractors.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/7/2016
We recommended the VA Northwest Health Network management, in conjunction with the Assistant Secretary for Information and Technology, ensure that ProCare personnel complete VA's information security awareness training and sign the Contractor Rules of Behavior.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/11/2017
We recommended the Assistant Secretary for Information and Technology conduct a site assessment of information security controls at the ProCare facility, to include a risk assessment to determine the extent that any sensitive veteran data may have been compromised and, if so, with appropriate corrective action, to ensure compliance with VA and Federal information security requirements.
Healthcare Inspection – Administrative Response to Deaths and Quality of Care Irregularities, VA North Texas Health Care System, Dallas, Texas
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14-02725-316

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2016
We recommended that the System Director ensure that the care of Patient A is evaluated, including a review of computerized tomography scan orders and imaging study results, and take action if appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/26/2016
We recommended that the System Director consider revising the Do Not Resuscitate Policy to include re-addressing Do Not Resuscitate orders status with patients prior to any procedures in the hospital.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the System Director ensure timely compliance with all elements of the Drug-Free Workplace Program.
Administrative Investigation - Misuse of Official Time, Denver VA Regional Office, Lakewood, CO
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15-02560-365

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/27/2017
We recommend that the Director, VBA Continental District, confer with the Offices of General Counsel (OGC), Human Resources (OHR), and Accountability Review to determine the appropriate administrative action to take, if any, against Ms. Murphy.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/27/2017
We recommend that the Director, VBA Continental District, review whether the privilege of credit hours and telework should be revoked and ensure that Ms. Murphy receives refresher training on VA’s policy for time and attendance, credit hours, and telework.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 3/27/2017
We recommend that the Director, VBA Continental District, confer with OGC and OHR concerning the 14 days in which Ms. Murphy was unable to fully account for her activities, determine whether she was absent without approved leave, and initiate action to recover pay she received when she was not present for duty.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/5/2017
We recommend that the Director, VBA Continental District, ensure that any VARO local policy for credit hours complies with VA policy and that employees use VA Form 5631 or the ETA system as the official means to record, certify, and report their time and attendance, to include any compensatory or credit hours earned or used.
Review of Alleged Mismanagement of the Ambulette Services at the New York Harbor Healthcare System
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15-04945-331

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 11/30/2016
We recommended the Under Secretary for Health implement an oversight process to ensure Integrated Oversight Process reviews arecompleted in accordance with established policies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2017
We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, develop a mechanism to ensure effective coordination between acquisition personnel when transferring contracting responsibilities.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/16/2017
We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, implement a process to ensure all acquisition personnel record contracting actions in the Electronic Contract Management System.
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