All Reports

Review of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 Pandemic
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21-02805-102
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Topics: COVID-19

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No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates provider knowledge and utilization of VA Video Connect technology, including resources such as the Digital Divide Consult, Connected Devices Support Program, and VVC Now and takes action as indicated.
No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates availability of clinical and administrative support to providers initiating and completing VA Video Connect encounters and clarifies expectations and requirements to ensure access to virtual care emulates in-person encounters.
No. 3
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health ensures education of providers and support staff regarding VA Video Connect scheduling processes.
The Veterans Health Administration Needs to Do More to Promote Emotional Well-Being Supports Amid the COVID-19 Pandemic
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21-00533-157
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Topics: COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health reviews the processes by which COVID-19 emotional well-being resources were developed and disseminated and takes action as needed to increase and ensure Veterans Integrated Service Network and facility leadership as well as facility staff’s awareness of available resources about the potential risks and signs of burnout.
Purchases of Smartphones and Tablets for Veterans’ Use during the COVID-19 Pandemic
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21-02125-132
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Topics: COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Establish a realistic goal for days in storage along with a process for closely monitoring days in storage and taking corrective actions when the goal is not met.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Perform a cost-benefit analysis in conjunction with VA contracting officials and the contractor to determine whether a new process can be implemented that initiates the data plan when a device is issued to the veteran or otherwise reduces unused plan costs.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,336,381.00
Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia
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21-01724-84
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Topics: COVID-19,Community Care,Care Coordination

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Veterans Integrated Service Network Director confirms that weekly calls with facility and Veterans Integrated Service Network leaders are held to discuss active Improvement Action Plans, progress made, timelines, and next steps.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director verifies that Improvement Action Plans, identifying areas of improvement and outlining recommendations, are in place for unmet national Care in the Community performance metrics.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director confirms that clinical reviews of COVID Priority 1 active consults are completed and documented, monitors compliance, and takes action as warranted.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director ensures a process is in place to review and address consults for patients who died prior to being scheduled or seen by a community care provider to determine if an adverse event occurred as a result of a delay in processing a patient’s consult.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director evaluates the effectiveness of strategies to manage the backlog of active consults and the use of urgent and emergent to prioritize consults for scheduling, determines if changes in practice are warranted, and documents the agreed upon process.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director conducts a review to determine who, outside Care in the Community staff, is facilitating appointment scheduling and evaluates if the scheduling assistance of other services is an effective use of resources, and establishes a standardized process to align practices.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Martinsburg VA Medical Center Director ensures Care in the Community staffing levels are adequate to support the processing of consults according to time frames set by the Veterans Health Administration.
Audit of Community Care Consults during COVID-19
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21-00497-46
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Topics: COVID-19,Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.
Systems and Tools Implemented to Track COVID-19 Vaccine Data
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21-00913-267
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Topics: COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health develop processes for verifying facility data entered on the Pharmacy Benefits Management Services’ SharePoint website (or any subsequent data collection tool) for vaccine supply and usage.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health develop a process to monitor the use of tools that have been fielded to standardize data entry for vaccine doses administered by VA medical facilities and clinics to minimize data entry errors, including the Computerized Patient Record System’s clinical reminder, the Occupational Health Record-keeping System 2.0’s guided data entry guidance, and reports that can be used to identify data entry errors in these systems, or in any subsequent systems that VA uses to collect data on vaccinations.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended the under secretary for health make sure that the Power BI dashboard data are reliable, accurate, and complete, and capture all vaccine data more accurately for VA medical facilities in the same healthcare system.
Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic
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20-03437-26
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Topics: COVID-19,Community Care

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.
Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois
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21-00553-285
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Topics: COVID-19,Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Great Lakes Health Care System Director evaluates whether administrative action is warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at the VA Illiana Health Care System, and takes action, as appropriate.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director ensures the plan to monitor and track face mask wearing by staff at the community living center adheres to current Centers for Disease Control and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as warranted.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director confirms that all community living center staff identified as requiring respiratory protection are fit tested, trained, and have ready access to respiratory devices.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director ensures a plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding staff with known community exposure to COVID-19, and monitors for compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding community living center residents with known exposure to individuals diagnosed with COVID-19, and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director ensures operability and use of the bed management system for tracking completion of room cleaning.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director oversees the completion and implementation of a policy for administering aerosol-generating procedures during the COVID-19 pandemic that adheres to Centers for Disease Control and Prevention guidance, and monitors compliance.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director evaluates the organizational approach for notifying managers of updated Veterans Health Administration policies and guidance for monitoring actions taken to ensure compliance with new requirements.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans Health Administration guidance related to community living center practices, including group activities, disseminated during emergent events such as a pandemic and maintains oversight of community living center leaders’ implementation of such guidance.
No. 10
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director directs community living center leaders to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing.
No. 11
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director evaluates the community living center standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure that it provides guidance with specific actions for staff to take when a resident tests positive for COVID-19.
No. 12
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director verifies that COVID-19 testing for community living center residents and staff occurs as required for both routine surveillance and in response to confirmed cases of COVID-19.
No. 13
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director confirms that the community living center COVID-19 standard operating procedure clearly communicates the process, including roles and responsibilities, for notification of a resident’s change in condition or room assignment and communicates the plan to all community living staff.
No. 14
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director executes a process to ensure that the facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the community living center, and when identified, creates a plan to mitigate and manage risk.
No. 15
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The VA Illiana Health Care System Director directs those conducting the facility’s after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.
Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina
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21-01304-275
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Topics: COVID-19,Patient Safety,Appointment Scheduling and Wait Times

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.
Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas
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20-03635-217
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Topics: COVID-19,Mental Health,Patient Safety

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
No. 8
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
No. 9
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.
Medical/Surgical Prime Vendor Contract Emergency Supply Strategies Available Before the COVID-19 Pandemic
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20-03075-138
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Topics: COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The under secretary for health direct the Medical Supplies Program Office to provide Veterans Integrated Service Network and VA medical facility chief logistics officers guidance on how to use and monitor the emergency and continuous supply strategies offered in prime vendors’ contingency plans to help mitigate acute emergency and continuous supply shortages during the current pandemic and future emergencies.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Acquisitions, Logistics, and Construction (OALC)
The Office of Acquisition, Logistics, and Construction direct the Strategic Acquisition Center’s Medical/Surgical Prime Vendor Program contracting officer to provide guidance to Veterans Integrated Service Network and VA medical facilities’ program contracting officer’s representatives on the emergency and continuous supply provisions in the contracts, and ensure contracting officers’ representatives inform network and facility managers of the strategies offered by the prime vendors.
Review of VHA’s Financial Oversight of COVID-19 Supplemental Funds
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20-02967-121
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Topics: COVID-19

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to implement internal control procedures to ensure the completeness and accuracy of the data in VA’s reports to the Office of Management and Budget and to Congress.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommends that the Principle Deputy Under Secretary for Health coordinate with VA’s Office of Management to execute data validation procedures to make certain that reports to the Office of Management and Budget and to Congress can be traced back efficiently to the source transactions.
Use and Oversight of the Emergency Caches Were Limited during the First Wave of the COVID-19 Pandemic
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20-03326-124
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Topics: COVID-19,Supplies and Equipment

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No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended that the under secretary for health initiate efforts to revise or amend VHA Directive 1047 to clarify when changes to emergency cache activation procedures are appropriate, and develop the communication and documentation requirements for these situations to ensure all relevant parties—including medical facility directors and pharmacy chiefs—are aware of and comply with any changes to routine activation protocols as well as the responsibilities they maintain.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended that the under secretary for health establish minimum time frames, for example by assessing Emergency Pharmacy Service’s data on the typical length of time it takes to replenish emergency cache inventory items, by which the Emergency Pharmacy Service initiates resupply orders to make sure caches are fully stocked with unexpired inventory.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
The OIG recommended that the under secretary for health make sure that the Emergency Pharmacy Service and the Watch Office are maintaining accurate and complete records of emergency cache activations.
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