All Reports

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.

Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.

Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.

Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantee’s premises and any adverse health or safety inspection results or similar findings made concerning the grantee’s premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.

Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSD’s clinical treatment housing model.

The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.

The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.

The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.

The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.

The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.

The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.

The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes solo and two-deep practitioners’ professional practice evaluations in a timely manner.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network chief medical officers and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes Ongoing Professional Practice Evaluations of chiefs of staff in each facility in a timely manner.

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, reviews state licensing board reporting processes at the network level to ensure compliance with Veterans Health Administration policy.

The Under Secretary for Health, in conjunction with the Veterans Integrated Service Network 8 Director, ensures the Chief Medical Officer oversees each facility’s annual self-assessment and confirms responses reflect accurate data.

Make sure the Office of Integrated Veteran Care develops contract language and/or maximum allowable rates to limit reimbursements that do not have a Medicare or VA fee schedule rate for Community Care Network claims.

Ensure the Office of Integrated Veteran Care improves oversight of healthcare claim payments to prevent, identify, and recover overpayments in a more timely manner.

Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction, collaborate to extend the contracting officer’s representatives’ designated responsibilities to include monitoring of healthcare invoices.

Make sure the Office of Integrated Veteran Care considers including dental contract reimbursement language in the current and/or future contracts that is consistent with other contract healthcare reimbursement methodology to limit dental contract reimbursements, not to exceed the amount the third-party administrators pay the providers.

Make certain the Office of Procurement, Acquisition, and Logistics develops sufficient oversight and internal controls over the contract modification process to prevent program overpayments.

Require the Office of Veteran Integrated Care and the Office of Acquisition, Logistics, and Construction to collaborate to explore potential recovery of dental payments to Optum.

Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction collaborate to establish oversight and internal controls for dental services provided through Community Care Network to prevent excessive reimbursements.