All Reports

Establish mechanisms to make sure business cases are developed, promptly reviewed, and approved as required by the Office of Management and Budget Circular A‑11 and VA Directive 0011.

Perform periodic reviews to verify that business cases comply with Office of Management and Budget Circular A‑11 requirements by being updated throughout a project’s life cycle to reflect changes in scope, schedule, and cost, and to verify that if changes exceed 10 percent of the initially approved business case, they are reported to the Office of Management and Budget.

Verify that milestones for the Louisville new medical center project are updated to incorporate critical user-requested changes and that these changes are completed in a timely manner to prevent further delays, while keeping the project within its authorized scope, cost, and schedule.

Establish controls to ensure the executive director of the Office of Construction and Facilities Management fulfills the responsibilities in VA Directive 0067 to incorporate National Environmental Policy Act analysis early on in all land acquisition, planning, design, and construction projects.

Conduct a comprehensive review of major construction project obligations to ensure all costs related to each project, including those recorded in separate funding lines, are included in the total estimated project costs reported to Congress, consistent with 38 U.S.C. § 8120, 31 U.S.C. § 1105, Office of Management and Budget Circular A‑11, and volume 8 of VA Financial Policy.

Update the responsibilities section of VA Directive 0067 to reflect the expectation that, before budget authorization, major construction projects must proactively identify advance planning fund requirements to support the initiation of NEPA environmental reviews during project development.

Provide the VA Office of Inspector General with an implementation schedule for an acquisition framework to enable monitoring of major construction project performance.

Assess options to expand and optimize automation tools, including artificial intelligence–based solutions, for request for services processing to reduce manual steps and promote efficiency.

Address system limitations that prevent identification of whether actions specific to requests for services have been taken or are pending, such as the delegated clinician review.

Review and update national standard operating procedures for request for services processing to clarify roles and responsibilities, address inappropriate practices, and reduce processing delays.

Develop processes or controls to help improve the accuracy and consistency of the use of the actual receipt date as the official date the Veterans Health Administration received the request for services to maintain accurate timeliness tracking.

Make sure facilities provide accurate notifications to community providers and notify veterans at key processing stages.

Implement mechanisms to provide routine oversight of the request for services process, including assessing data accuracy and the timeliness of request processing, to reinforce accountability and support corrective action.

The Medical Center Director takes appropriate action so emergency department and dental clinic staff maintain a clean and safe environment and repair or replace damaged items to support effective disinfection, as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Medical Center Director takes appropriate action so emergency department staff establish and maintain an environment that protects patients’ privacy, as required by the Joint Commission standard, Rights and Responsibilities of the Individual 01.01.01.

The Medical Center Director takes appropriate action so all services develop workflows in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients, including defining responsibilities of non-provider personnel for communicating test results to patients.

The Director installs detectable warning surfaces at all walkways that transition to roadways, in accordance with VA’s PG-18-10, Site Design Manual.

The Associate Chief of Staff, Mental Health develops and implements written processes to ensure treatment planning on the inpatient mental health unit aligns with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA Medical Points of Service requirements. 

The Associate Chief of Staff, Mental Health requires a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit, in alignment with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Facility Director ensures implementation of a recovery-oriented environment on the inpatient mental health unit, consistent with Veterans Health Administration’s Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Facility Director develops and implements a written standard operating procedure for the use of video monitoring on the inpatient mental health unit, as required by Veterans Health Administration Office of Mental Health Standard Operating Procedure 1160.06.1, “Standard Operating Procedure for Maintaining Safety and Security on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06.”

The Chief of Staff ensures that only healthcare staff have access to video monitoring in treatment areas and that video equipment is used for monitoring, not recording, in accordance with Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

The Facility Director posts signage to notify veterans of video monitoring on the inpatient mental health unit, as required Veterans Health Administration Directive 1078, Privacy of Persons Regarding Photographs, Digital Images and Video or Audio Recordings.

The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements in Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Chief of Staff requires documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administrationand develops a plan to monitor for sustained compliance, in accordance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures.

The Chief of Staff ensures discharge instructions include appointment locations in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”

The Facility Director requires all Interdisciplinary Safety Inspection Team members attend biannual inspections and record attendance consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.  

The Facility Director directs the Interdisciplinary Safety Inspection Team to provide biannual inspection attendance to the Comprehensive Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.

The Facility Director ensures staff complete appeals within the required time frame in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.1, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Inspections and Appeals Under VHA [Veterans Health Administration] Directive 1167.”

The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Units Treating Suicidal Patients.

Improve vulnerability management processes so that all vulnerabilities are identified and mitigated; for vulnerabilities that cannot be mitigated by VA deadlines, create plans of action and milestones.

Improve the baseline configuration process to make sure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.

Confirm appropriate network isolation and protections for all medical devices and special‑purpose systems hosted on the Lovell Federal Healthcare System networks.

Separate the duties of maintaining physical blank key stock and making keys to improve physical access controls over key inventories.

Improve the process for monitoring and servicing uninterruptible power supplies that support the network infrastructure.

Complete the installation of grounding measures for all communications closets.

Establish a process to make sure a witness observes the destruction of temporary paper files that contain personally identifiable information and protected health information.

In collaboration with the director of Veterans Integrated Service Network 16, verify engineering staff are complying with Veterans Health Administration policies and guidance associated with architectural and engineering design review and inspection procedures.

Verify that all engineering staff understand and are trained on VA design and physical security requirements related to minor and nonrecurring maintenance construction projects.

Verify that engineering staff who develop independent government cost estimates are sufficiently trained on developing a statement of work and how these documents affect the cost estimates.

Ensure engineering staff are documenting their review and acceptance of architectural and engineering designs as required by the Federal Acquisition Regulation before the solicitation of construction contracts.

The Director takes appropriate actions to maintain a clean environment to reduce the risk of infection, in accordance with Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program.

The Director takes appropriate actions so staff change privacy curtains to reduce the risk of infection and supervisors monitor compliance, in accordance with the facility’s Infection Prevention and Control Manual.

The Director takes appropriate action so staff update the facility policy for communicating test results and develop service-level workflows that describe team members’ roles in the process, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.

The Veterans Integrated Service Network Director and facility Director take appropriate action for the surveillance system to be fully operational.

The Director takes appropriate actions to secure portable liquid nitrogen tanks and store the tanks according to the National Fire Protection Association’s Compressed Gases and Cryogenic Fluids Code, NFPA 55 requirements.

The Facility Director develops and implements clearly defined written processes for providing mental health care to veterans on medical units.

The Facility Director develops and implements written processes to ensure compliance with state involuntary commitment requirements.

The Chief of Staff ensures documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures veterans’ discharge instructions include the appointment location in easy-to-understand language.

The Chief of Staff ensures discharge instructions are free of medical abbreviations and includes the purpose for each listed medication and develops a plan to monitor for sustained compliance.

The Chief of Staff directs staff to complete or review veterans’ suicide prevention safety plans prior to discharge from the acute inpatient mental health unit and develops a plan to monitor for sustained compliance.

The Facility Director ensures the Interdisciplinary Safety Inspection Team adheres to Veterans Health Administration requirements, including attendance at environment of care inspections, record of required members’ attendance at inspections in meeting minutes, and develops a plan to monitor for sustained compliance.

The Facility Director directs staff to complete the required Mental Health Environment of Care Checklist training.

The Healthcare System Director ensures the Mental Health Executive Council includes ongoing veteran representation, in accordance with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA [Veterans Health Administration] Medical Points of Service.

The Associate Chief of Service, Mental Health ensures the local recovery coordinator serves in a full-time capacity, in accordance with Veterans Health Administration requirements Directive 1163, Psychosocial Rehabilitation and Recovery Services. 

The Healthcare System Director ensures the physical environment on the inpatient mental health unit reflects recovery-oriented principles according to Veterans Affairs’ Design Guide for Inpatient Mental Health & Residential Rehabilitation Treatment Program Facilities.

The Chief of Staff ensures compliance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures requirements related to documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration, and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures veterans’ discharge instructions include the follow-up mental health appointment location information in easy-to-understand language, in accordance with Veterans Health Administration’s “Clinic Profile Management Business Rules,” and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures discharge instructions include the purpose for each listed medication, consistent with Veterans Health Administration Directive 1345, Medication Reconciliation, and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures staff provide a copy of the suicide prevention safety plan to veterans upon discharge from the inpatient unit, in accordance with Veterans Health Administration Office of Mental Health and Suicide Prevention Standard Operating Procedure 1160.06.2, “Standard Operating Procedure for Core Clinical Processes on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06,” and develops a plan to monitor for sustained compliance.

The Healthcare System Director instructs the Interdisciplinary Safety Inspection Team to record and report attendance of inspections to the Environment of Care Committee, as required by Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, and develops a plan to monitor for sustained compliance.

The Healthcare System Director develops and implements a plan to monitor Mental Health Environment of Care Checklist training completion for sustained compliance, consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.

The Healthcare System Director ensures that Mental Health Environment of Care Checklist training completion attestation is accurately documented, in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.2, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Attestations Under VHA [Veterans Health Administration] Directive 1167,” and develops a plan to monitor for sustained compliance.

The Healthcare System Director ensures the Mental Health Executive Council includes veteran representation, in accordance with Veterans Health Administration Directive 1160.01, Uniform Mental Health Services in VHA [Veterans Health Administration] Medical Points of Service.

The Chief of Mental Health ensures staff develop and implement a local standard operating procedure for staff education and training on recovery-oriented care, consistent with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Chief of Mental Health ensures the local recovery coordinator conducts reviews of inpatient training material to maintain a recovery-oriented approach, in accordance with Veterans Health Administration Directive 1163, Psychosocial Rehabilitation and Recovery Services.

The Chief of Mental Health considers consultation with the Office of Mental Health to ensure facility policy aligns with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services, on veterans’ access to personal clothing on the inpatient units.

The Chief of Mental Health ensures a minimum of four daily hours of recovery-oriented, interdisciplinary programming on the inpatient mental health units, consistent with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services, and develops a plan to monitor for sustained compliance.

The Healthcare System Director develops and implements written processes to ensure compliance with involuntary commitment requirements, in accordance with Veterans Health Administration Directive 1160.06(1), Inpatient Mental Health Services.

The Chief of Staff ensures compliance with Veterans Health Administration Directive 1004.01(3), Informed Consent for Clinical Treatments and Procedures, requirements related to documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications prior to administration and develops a plan to monitor for sustained compliance.

The Chief of Staff ensures veterans’ discharge instructions include the appointment location in easy-to-understand language, consistent with Veterans Health Administration’s “Clinic Profile Management Business Rules.”

In accordance with Veterans Health Administration Directive 1345, Medication Reconciliation, and Veterans Health Administration Health Information Management’s Health Record Documentation Program Guide Version 1.3, the Chief of Staff ensures discharge instructions include the purpose and dosing information for each listed medication in easy-to-understand language and develops a plan to monitor for sustained compliance.

The Chief of Staff directs staff to complete the Columbia-Suicide Severity Rating Scale within 24 hours before veterans’ discharge, consistent with Department of Veterans Affairs (VA) Suicide Risk Identification Strategy Minimum Requirements by Setting, and develops a plan to monitor for sustained compliance.

The Chief of Staff directs staff to complete or review veterans’ suicide prevention safety plans prior to discharge from the inpatient mental health units, in accordance with Veterans Health Administration Office of Mental Health and Suicide Prevention Standard Operating Procedure 1160.06.2, “Standard Operating Procedure for Core Clinical Processes on Inpatient Mental Health Units under VHA [Veterans Health Administration] Directive 1160.06,” and develops a plan to monitor for sustained compliance.

The Healthcare System Director directs staff to complete required suicide prevention training, according to the “Office of Suicide Prevention Suicide Prevention Mandatory Training Dashboard FAQ [Frequently Asked Questions],” and develops a plan to monitor for sustained compliance.

The Healthcare System Director instructs the Interdisciplinary Safety Inspection Team to adhere to Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, requirements related to attendance at inspections and record of attendance in meeting minutes, and develops a plan to monitor for sustained compliance.

The Healthcare System Director implements processes to ensure Interdisciplinary Safety Inspection Team staff accurately identify and document safety hazards, in accordance with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients.

The Healthcare System Director directs inpatient staff and Interdisciplinary Safety Inspection Team members to complete Mental Health Environment of Care Checklist training requirements, consistent with Veterans Health Administration Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, and develops a plan to monitor for sustained compliance.

The Healthcare System Director ensures that Mental Health Environment of Care Checklist training completion is documented in attestations, in accordance with Veterans Health Administration Office of Mental Health Standard Operating Procedure 1167.2, “Standard Operating Procedure for Submission of MHEOCC [Mental Health Environment of Care Checklist] Attestations Under VHA Directive 1167,” and develops a plan to monitor for sustained compliance.

Develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.

Ensure all relevant supply chain staff receive appropriate and recurring training and require supervisors to perform ongoing monitoring—including periodic inventory reviews and root‑cause analyses—to strengthen controls over VA supplies.

Develop and implement, in collaboration with the Veterans Integrated Service Network, local procedures that require custodial officers to notify supply chain staff when equipment is relocated, and establish protocols to validate and update equipment location and ensure equipment items are properly tagged.

Ensure expendable supplies labeled expired are, in fact, expired and appropriate documentation is completed before turning the supplies in.

Address the physical security issues discussed in this report and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouses.

Evaluate contractor performance under the contracts awarded for inventory management systems in the Augusta VA Health Care System and take appropriate action to ensure performance in accordance with the contract and to recover funds.

Ensure supply chain management staff effectively address deficiencies identified during Veterans Integrated Service Network quality control reviews.

Confer with the VA Office of General Counsel to determine whether VA should assert a claim to recover the $11.2 million paid for services not received

Evaluate and take any needed actions to make sure policies and procedures require appropriate officials to accurately ascertain information security requirements for contracts that involve sensitive information prior to award.