OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

OIG Reports

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Health Care System Director submits ratification requests to the Veterans Health Administration’s Head of Contracting Activity for the split purchases and the purchases that exceeded the micropurchase threshold identified in the OIG report for calendar years 2014 and 2015.

No. 2   to Veterans Health Administration (VHA)

The Health Care System Director provides additional training for purchase cardholders and approving officials focused on avoiding split purchases and complying with micropurchase thresholds.

No. 3   to Veterans Health Administration (VHA)

The Health Care System Director establishes a rigorous monitoring mechanism to ensure management controls are in place and working to identify and prevent improper purchase card transactions.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Unwarranted Medical Reexaminations for Disability Benefits

7/17/2018 | 17-04966-201 | Summary | Report | 4 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Benefits establishes internal controls sufficient to ensure that a reexamination is necessary prior to employees ordering it, and modifies VBA procedures as appropriate to reflect these improved business processes.

No. 2   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits takes steps to prioritize the design and implementation of system automation reasonably designed to minimize unwarranted reexaminations.

No. 3   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits enhances VBA’s quality assurance reviews to evaluate whether employees correctly requested reexaminations and categorize unwarranted reexaminations as errors.

No. 4   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits conducts a special focused quality improvement review of cases with unwarranted reexaminations to develop data sufficient to understand and redress the causes of any avoidable errors.

Total Monetary Impact of All Recommendations

Open: $ 100,600,000.00
Closed: $ 0.00

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Facility Director ensures that Facility managers coordinate and implement uniform Program policies and procedures relating to supervision of patients, and that Facility staff consistently follow those policies and procedures.

No. 2   to Veterans Health Administration (VHA)

The Facility Director ensures that the Mental Health Treatment Coordinator and interdisciplinary team develop and document the interdisciplinary treatment plan, as required by Veterans Health Administration and Facility policy.

No. 3   to Veterans Health Administration (VHA)

The Facility Director ensures that the Program offers patient treatment, daily, as required by Veterans Health Administration.

No. 4   to Veterans Health Administration (VHA)

The Facility Director ensures that Program managers regularly evaluate restrictions to patient privileges and methods to reinstate restricted or lost patient privileges, as required by Veterans Health Administration.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures that staff document Program patient care in the electronic health record within Veterans Health Administration and Facility requirements and timeframes.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Ongoing Professional Practice Evaluations include service-specific performance data and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director and Assistant Director ensure required team members consistently participate on environment of care rounds and monitor team members’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Assistant Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Facility Director ensures that controlled substance inspectors perform reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors nurses’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Beckley VA Medical Center Director reviews consult management practices and ensuresconsult timeliness.

No. 1   to Veterans Health Administration (VHA)

The Beckley VA Medical Center Director reviews consult management practices and ensuresconsult timeliness.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The James E. Van Zandt VA Medical Center Director ensures that the James E. Van Zandt VA Medical Center’s anesthesia needs and services are evaluated and align with Veterans Health Administration and James E. Van Zandt VA Medical Center policies.

No. 2   to Veterans Health Administration (VHA)

The James E. Van Zandt VA Medical Center Director ensures that service chief provider oversight includes facility-specific privileges and provider-specific Ongoing Professional Practice Evaluations.

No. 3   to Veterans Health Administration (VHA)

The James E. Van Zandt VA Medical Center Director ensures that James E. Van Zandt VA Medical Center leaders consult with the Office of Chief Counsel to determine if the anesthesiologist should be reported to the National Practitioner Data Bank and the State Licensing Board for administrating medications inconsistent with the Food and Drug Administration approved manufacturer’s instructions.

No. 4   to Veterans Health Administration (VHA)

The James E. Van Zandt VA Medical Center Director ensures that the Patient Advocate enters all patient complaints into the Patient Advocate Tracking Systems database; documents issue descriptions and actions taken; and tracks all complaints to resolution.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

Veterans Integrated Service Network 20 Director conducts a management review of the care of the patient who is the subject of this report, and confers with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action.

No. 2   to Veterans Health Administration (VHA)

The Facility Director implements a systematic approach to review prescribing of controlled substances to individuals at high-risk for substance abuse or misuse.

No. 3   to Veterans Health Administration (VHA)

The Facility Director strengthens processes that foster interdisciplinary collaboration for the management of patients with complex clinical pain and allows referrals from all Facility staff.

No. 4   to Veterans Health Administration (VHA)

The Facility Director ensures that policy and practice is consistent with Veterans Health Administration Directive 1005, Informed Consent for Long-term Opioid Therapy for Pain.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures provider accountability for compliance with Veterans Health Administration and Facility controlled substance policies, including opioid informed consent policies.

No. 6   to Veterans Health Administration (VHA)

The Facility Director strengthens the Facility Board that is responsible for controlled substances safety, including clarification of roles, responsibilities, and authority; and the development of clearly written definitions and entry criteria for Category II patient record flags in accordance with Veterans Health Administration policy.

No. 7   to Veterans Health Administration (VHA)

The Facility Director maintains full compliance with the Veterans Health Administration’s peer review directive, including but not limited to the selection of impartial reviewers and removing the service chief level review from the Facility peer review process.

No. 8   to Veterans Health Administration (VHA)

The Facility Director performs a focused professional practice evaluation on primary care provider 1’s opioid prescribing practices in high-risk patients.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The VISN 1 Medical Facility Director ensures that staff receive education about the process for initiating Medication Assisted Therapy for patients enrolled in the Program.

No. 2   to Veterans Health Administration (VHA)

The VISN 1 Medical Facility Director ensures that a standard operating procedure is issued to effectively track patients enrolled in the Program who fail to show for appointments at off-site substance abuse day programs.

No. 3   to Veterans Health Administration (VHA)

The VISN 1 Medical Facility Director ensures that all appropriate staff receive training regarding the standard operating procedure for tracking patients enrolled in the Program who fail to show for appointments in at off-site substance abuse day programs.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Acting Veterans Integrated Service Network 21 Director ensures the Director of the VA Southern Nevada Healthcare System develops and implements effective processes such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetics Laboratory operates in a manner that maximizes its personnel and on hand inventory to provide veterans with timely and cost effective fitting services for compression garments and orthotic shoes.

No. 2   to Veterans Health Administration (VHA)

The Acting Veterans Integrated Service Network 22 Director ensures the VA San Diego Healthcare System Director takes steps such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetic Service operates in a manner that maximizes its resources to provide veterans with timely and cost effective fitting services compression garments and orthotic shoes.

No. 3   to Veterans Health Administration (VHA)

The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements effective processes to monitor purchasing employees’ usage of all non item Healthcare Common Procedure Coding System codes to ensure the proper utilization of these codes.

No. 4   to Veterans Health Administration (VHA)

The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements a process to examine the 4,530 consults closed, but not cloned, by purchasing employees using the NR018 code from October 2014 through May 2016 and take necessary action to ensure veterans received their prescribed prosthetic or orthotic item(s).

Total Monetary Impact of All Recommendations

Open: $ 0.00
Closed: $ 242,000.00

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7/19/2018 3:57:14 AM


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