All Reports

Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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15-00153-508

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that the information technology server closet at the Belmont County VA Clinic is maintained according to information technology safety and security standards.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 6/29/2016
We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Inspection of VA Regional Office Sioux Falls, South Dakota
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15-01860-502

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended the Sioux Falls VA Regional Office Director conduct a review of the 22 temporary 100 percent disability evaluations remaining from their inspection universe as of February 11, 2015, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended the Sioux Falls VA Regional Office Director implement a plan to improve the effectiveness of the second-signature review process for special monthly compensation and ancillary benefits claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/15/2015
We recommended the Sioux Falls VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Combined Assessment Program Review of the Durham VA Medical Center, Durham, North Carolina
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15-00615-513

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
We recommended that the Surgical Work Group meet monthly.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/25/2016
We recommended that the facility designate a clinical subject matter expert to oversee emergency airway management.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/19/2016
We recommended that the facility ensure clinicians designated for out of operating room airway management coverage have current scopes of practice and documentation of all required elements and that facility managers monitor compliance.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Robley Rex VA Medical Center, Louisville, Kentucky
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15-00170-517

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that patient-identifiable information on laboratory specimens is secured during transport from the Newburg VA Clinic to the Robley Rex VA Medical Center.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that staff protect and secure patient-identifiable information at the Newburg VA Clinic.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinic Registered Nurse Care Managers receive motivational interviewing within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/8/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/15/2016
We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by VHA and local policy and that compliance is monitored.
Follow-up Review of VA’s Veterans Benefits Management System
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13-00690-455

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No. 1
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 9/14/2015
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, implement improved cost controls and stabilize Veterans Benefits Management System functionality requirements for the remainder of planned system development to restrict further cost increases.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 5/13/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, perform a formal budget versus cost analysis to identify actual costs expended in support of the Veterans Benefits Management System development effort.
No. 3
Not Implemented Recommendation Image, X character'
to Information and Technology (OIT)
Closure Date: 9/14/2015
We recommended the Executive in Charge for the Office of Information and Technology perform market analyses on all future Space and Naval Warfare Systems Command Atlantic task orders to determine whether the continued use of the interagency agreements is in the best interest of the Department.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 2/21/2018
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, establish a clear strategy and plan to decommission legacy systems, eliminate redundant systems operations, and reduce system maintenance costs.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 8/9/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, fully develop and implement Veterans Benefits Management System electronic workflow and workload brokering functionality to facilitate more efficient claims processing.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, provide adequate training with each Veterans Benefits Management System release to ensure VA Regional Office users fully benefit from the enhanced functionality provided.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology implement an improved Veterans Benefits Management System network infrastructure to mitigate single points of failure and reduce the network performance issues across the enterprise.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA),Information and Technology (OIT)
Closure Date: 3/23/2016
We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, develop sufficient Veterans Benefits Management System performance metrics to demonstrate the system is improving VA¿s ability to efficiently process claims as compared to legacy practices.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 5/13/2016
We recommended the Executive in Charge for the Office of Information and Technology minimize the use of manual requirements tracking processes and maximize the use of automated application lifecycle management tools to manage requirements traceability in accordance with industry best practices.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 27,000,000.00
Inspection of VA Regional Office San Diego, California
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15-00399-410

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/23/2016
We recommended the San Diego VA Regional Office Director develop and implement a plan to ensure staff take timely actions on reminder notifications to request medical reexaminations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 5/16/2016
We recommended the San Diego VA Regional Office Director conduct a review of the 388 temporary 100 percent disability evaluations remaining from our inspection universe as of October 17, 2014, and take appropriate action.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/23/2016
We recommended the San Diego VA Regional Office Director ensure staff receive refresher training on proper evaluation of special monthly compensation and ancillary benefits claims and implement plans to ensure the effectiveness of that training.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/23/2016
We recommended the San Diego VA Regional Office Director develop and implement a plan to increase the effectiveness of the station's second-signature process for cases with special monthly compensation and ancillary benefits.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/23/2016
We recommended the San Diego VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Inspection of VA Regional Office Fort Harrison, Montana
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15-02706-485

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2016
We recommended the Fort Harrison VA Regional Office Director conduct a review of the 79 temporary 100 percent disability evaluations remaining from our inspection universe as of March 10, 2015, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/17/2016
We recommended the Fort Harrison VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
Inspection of VA Regional Office Lincoln, Nebraska
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15-02614-434

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Lincoln VA Regional Office Director conduct a review of the 81 temporary 100 percent disability evaluations remaining from our inspection universe as of March 5, 2015, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended the Lincoln VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Review of Alleged Mismanagement at the Health Eligibility Center
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14-01792-510

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/21/2016
We recommended the Under Secretary for Health provide guidance concerning how long applications may remain pending before reaching a final determination.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health assign an accountable official responsible to implement a plan to correct current data integrity issues in the Enrollment System.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
We recommended the Under Secretary for Health develop and execute a project management plan to ensure that Enrollment System data are fully evaluated and properly categorized.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health implement controls to ensure that future enrollment data are accurate and reliable before being entered in the Enrollment System.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health implement effective policies and procedures to accurately and timely identify deceased individuals with records in the Enrollment System and record their changed status in the system.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/25/2016
We recommended the Under Secretary for Health establish appropriate policies and procedures to ensure Health Eligibility Center workload data are not deleted or changed without appropriate management review, approval, and audit trails.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to Health Eligibility Center workload data are based upon specific job duties and the need to know.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/17/2016
We recommended the Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the first three allegations, determine if administrative action should be taken against any senior Veterans Health Administration officials involved, and ensure that appropriate action is taken.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 1/22/2016
We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/21/2016
We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 4/21/2016
We recommended that the Assistant Secretary for Information and Technology develop a monthly schedule to test whether Health Eligibility Center workload data are backed up properly and to provide the results of such testing to the Chief Business Office.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Information and Technology (OIT)
Closure Date: 6/29/2016
We recommended the Assistant Secretary for Information and Technology confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the lack of controls over the Workload Reporting and Productivity tool, determine if administrative action should be taken against any senior Office of Information Technology officials involved, and ensure that appropriate action is taken.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/22/2016
We recommended the Under Secretary for Health perform monthly comparisons between Workload Reporting and Productivity reports and enrollment records to ensure the timely processing of applications and related documents.
Healthcare Inspection – Alleged Delayed Mental Health Treatment and Other Care Issues, Kansas City VA Medical Center, Kansas City, MO
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14-03531-402

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/23/2016
We recommended that the Interim Under Secretary for Health review relevant inpatient program occupancy rates and wait times system-wide and determine whether additional guidance to facilities is needed to help ensure that the number of patients served through those programs is optimized.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2016
We recommended that the Facility Director ensure that processes be strengthened to ensure appropriate follow through on consults that are cancelled for administrative reasons.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2016
We recommended that the Facility Director ensure that Emergency Department providers fully evaluate patients with abnormal findings and make those evaluations readily accessible to other providers.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/21/2016
We recommended that the Facility Director ensure that patients are evaluated and referred for treatment for certain health concerns if exhibited by patients presenting to the Emergency Department, when appropriate.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Maine Healthcare System, Augusta, Maine
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15-00154-500

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/17/2017
We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/20/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/26/2016
We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 10/11/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages
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15-03063-511
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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: 9/28/2016
We recommended that the Under Secretary for Health ensure that the Veterans Health Administration further develops staffing models for critical need occupations.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 9/28/2016
We recommended that the Under Secretary for Health review the data on regrettable losses in this report and Veterans Integrated Service Network Workforce Succession Strategic Plans and, if appropriate, consider implementing measures to reduce such losses.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Durham VA Medical Center, Durham, North Carolina
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15-00158-499

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that review of the hazardous materials inventory occurs twice within a 12-month period at the Raleigh II CBOC.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the staff at the Raleigh II CBOC participate in scheduled emergency management training and exercises.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by local policy.
Review of VHA’s Alleged Mishandling of Ophthalmology Consults at the Oklahoma City VAMC
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15-02397-494

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure patients affected by inappropriately discontinued ophthalmology consults receive the necessary eye care.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 4/7/2016
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center initiate a review of discontinued teleretinal imaging consults and take action to provide eye care when necessary.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/31/2015
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that guidance and responsibilities for making referrals on discontinued and cancelled consults is well-defined and formalized into policy.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that staff responsible for initiating and processing consults are properly trained on all applicable guidance and policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 1/14/2016
We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that all referring providers with electronic notifications responsibility receive adequate training.
Combined Assessment Program Review of the Battle Creek VA Medical Center, Battle Creek, Michigan
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15-00606-495

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure that credentialing and privileging folders do not contain non-allowed information.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure patient care areas are clean and monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that employees secure medication carts when not in use and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers maintain auditory privacy in all intake/exam areas and monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that facility managers revise the Radiology Service computed tomography quality assurance guideline to include radiologist review of appropriateness of computed tomography orders and specification of protocol prior to scans.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that facility managers comply with Veterans Health Administration directive requirements for exempted facilities, or if facility managers plan emergency intubation responses with onsite employees, they comply with Veterans Health Administration requirements for non-exempted facilities.
Inspection of VA Regional Office Phoenix, Arizona
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15-01381-437

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 9/17/2015
We recommended the Phoenix VA Regional Office Director conduct a review of the 325 temporary 100 percent disability evaluations remaining from their inspection universe as of December 17, 2014, and take appropriate action.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2016
We recommended the Phoenix VA Regional Office Director ensure frequent refresher training for processing higher levels of special monthly compensation and ancillary benefits claims.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2016
We recommended the Phoenix VA Regional Office Director implement a written plan to ensure oversight and prioritization of benefits reduction cases and related hearings.
Review of Community Based Outpatient Clinics and Other Outpatient Clinics of San Francisco VA Health Care System, San Francisco, California
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15-00156-490

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 5/10/2016
We recommended that hand hygiene compliance is monitored at the San Francisco VA Clinic and reported to the Infection Control Committee.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended that San Francisco VA Clinic staff store medical waste in a secure location.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 3/9/2017
We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 2/19/2016
We recommended that clinic staff ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2016
We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2016
We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/22/2016
We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Audit of Fiduciary Program Controls Addressing Beneficiary Fund Misuse
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13-03922-453

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2015
We recommended the Under Secretary for Benefits revise policy to require timely removal of a fiduciary from all assigned beneficiaries when an individual case of misuse has been determined.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 2/27/2017
We recommended the Under Secretary for Benefits retroactively establish debts for all fiduciaries who VBA determined misused beneficiary funds during calendar year 2013.
No. 3
Not Implemented Recommendation Image, X character'
to Veterans Benefits Administration (VBA)
Closure Date: 8/27/2015
We recommended the Under Secretary for Benefits revise policy to include clear timeliness standards from the time the hubs determine misuse occurred to the time Pension and Fiduciary Service completes the negligence determination.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 4/7/2017
We recommended the Under Secretary for Benefits ensure the processing of all misuse actions are incorporated into quality reviews of Fiduciary Program operations.
Inspection of VA Regional Office, Winston-Salem, North Carolina
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15-00452-411

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/28/2015
We recommended the Winston-Salem VA Regional Office Director conduct a review of the 597 temporary 100 percent disability evaluations remaining from our universe as of October 8, 2014, and take appropriate actions.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/28/2015
We recommended the Winston-Salem VA Regional Office Director develop and implement a plan to ensure claims processing staff receive additional training on required actions relating to required medical reexaminations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 12/28/2015
We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure staff receive refresher training on processing higher-level special monthly compensation claims.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Benefits Administration (VBA)
Closure Date: 8/4/2016
We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
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