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

OIG Reports

| 18-02405-146 | Summary | Report

Recommendations (14)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director ensures implementation of system-wide comprehensive environment of care practices and a safe, sanitary, and high-quality environment consistent with Veterans Health Administration policy.

No. 2   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director makes certain that Environmental Management Service managers establish standard operating procedures and consistent processes for staff training.

No. 3   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director implements a standardized process and accountability for validating Environmental Management Service staff competencies.

No. 4   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director verifies compliance with Veterans Health Administration policies for Sterile Processing Services controls.

No. 5   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director complies with Veterans Health Administration policies developed to support Infection Prevention and Control Program issues identified in this report.

No. 6   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director ensures that hot water temperature systems are 124 degrees Fahrenheit or higher to inhibit Legionella growth.

No. 7   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Chief of Staff and Associate Director of Patient Care Services implements a standardized process, consistent with Veterans Health Administration policy, to notify clinical staff involved in direct patient care when routine environmental water testing is positive for Legionella to increase diagnostic awareness.

No. 8   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director continues to recruit and hire for hospitalist vacancies.

No. 9   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director monitors action plans for the Mental Health Strategic Analytics for Improvement and Learning measures.

No. 10   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director completes a review of mental health staffing and continues efforts to recruit and hire for Mental Health Service vacancies.

No. 11   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 22 Director verifies that the Loma Linda VA Health Care System Director implements action items from previous external Veterans Health Administration site reviews.

No. 12   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director makes certain that senior leaders consistently attend comprehensive environment of care monitoring rounds.

No. 13   to Veterans Health Administration (VHA)

The VA Loma Linda Health Care System Director designates staff members to consistently enter data into the Comprehensive Environment of Care Assessment and Compliance Tool and takes action, as necessary, to complete or address environment of care deficiencies to meet Environmental Program Service goals.

No. 14   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 22 Director establishes a Veterans Integrated Service Network comprehensive environment of care policy and the VA Loma Linda Health Care System Director implements a facility level policy as required.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-04676-142 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief Business Office revenue-utilization review and monitors the committee’s compliance.

No. 2   to Veterans Health Administration (VHA)

The facility director ensures the Acute and Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.

No. 3   to Veterans Health Administration (VHA)

The chief of staff makes certain that the Medicine Service Line chief includes required gastroenterology-specific criteria in ongoing professional practice evaluations of gastroenterology practitioners and monitors the Medicine Service Line chief’s compliance.

No. 4   to Veterans Health Administration (VHA)

The associate director confirms storage rooms meet fire safety requirements by maintaining the required amount of open space between fire sprinkler deflectors and the top of stored items and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The associate director ensures that managers store clean and dirty medical equipment separately and monitors managers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The facility director makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.

No. 7   to Veterans Health Administration (VHA)

The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.

No. 8   to Veterans Health Administration (VHA)

The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.

No. 9   to Veterans Health Administration (VHA)

The facility director confirms that the Women Veterans Health Committee includes required core members, designated members consistently attend meetings, and monitors the committee’s compliance.

No. 10   to Veterans Health Administration (VHA)

The chief of staff ensures that program managers implement a process for tracking results notification and follow-up care data for abnormal cervical cancer screenings and monitors program managers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-04178-46 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Acquisitions, Logistics, and Construction (OALC)

The Technology Acquisition Center associate executive director provide written requirements, in designation memoranda or other written medium, that identify the method and level of detail required for program office contracting officers’ representatives to adequately document their review of contractor deliverables and determination of acceptability.

No. 2   to Office of Acquisitions, Logistics, and Construction (OALC)

The Technology Acquisition Center associate executive director develop procedures for Technology Acquisition Center contracting officers to ensure review and acceptability of contractor deliverables is adequately documented in contract files to help prevent improper payments.

No. 3   to Office of Acquisitions, Logistics, and Construction (OALC)

The Technology Acquisition Center associate executive director develop timeliness requirements for program office contracting officers’ representatives to submit contractor performance assessments.

No. 4   to Office of Acquisitions, Logistics, and Construction (OALC)

The Technology Acquisition Center associate executive director develop written follow-up procedures that standardize the actions Technology Acquisition Center contracting officers should take when program office contracting officers’ representatives do not comply with the developed timeliness requirements.

No. 5   to Office of Acquisitions, Logistics, and Construction (OALC)

The Technology Acquisition Center associate executive director implement procedures to monitor Technology Acquisition Center contracting officers’ actions through compliance reviews to ensure they adhere to written procedures.

No. 6   to Office of Acquisitions, Logistics, and Construction (OALC)

The Technology Acquisition Center associate executive director assess the risk introduced by removing the requirement to review Past Performance Information Retrieval System records and implements a control that mitigates this risk.

No. 7   to Office of Acquisitions, Logistics, and Construction (OALC)

The Technology Acquisition Center associate executive director enhance written procedures by providing Technology Acquisition Center contracting officers with standards that define higher-risk financial stability risk scores and subsequent actions that should be taken when these scores are identified.

Total Monetary Impact of All Recommendations

Open: $ 37,500,000.00
Closed: $ 0.00

| 17-03399-140 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health Care System Director confirms current dermatology clinic nursing practice requirements related to ensuring informed consent prior to initiating phototherapy are followed and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health Care System Director ensures dermatology clinic registered nurse training and competencies are completed as required and tracked for compliance.

No. 3   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health Care System Director reviews facility policy to ensure guidance clearly delineates environmental actions to be taken following identification of bed bugs.

No. 4   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health Care System Director ensures that all Gulf Coast Veterans Health Care System staff are trained on the policy addressing environmental actions to be taken following identification of bed bugs and track compliance.

No. 5   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health Care System Director ensures that the Patient Safety Manager completes all actions identified in the subject adverse event review.

No. 6   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 16 Director reviews the Gulf Coast Veterans Health Care System policy related to the confidentiality of fact-finding reviews to evaluate if the initiation of such reviews, including the one conducted in relation to this patient, is consistent with the purpose of maintaining the confidentiality of quality management activities, and takes action as necessary.

No. 7   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 16 Director reviews and evaluates the proposed and actual disciplinary actions taken by Gulf Coast Veterans Health Care System managers related to the events of the day in question, and takes action as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-04266-115 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits improve the exam management systems to ensure visibility of the information needed to conduct adequate oversight of contracted disability exam cancellations.

No. 2   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits ensure staffing is sufficient so that the Medical Disability Examination Program can perform adequate oversight of contracted disability exam cancellations.

No. 3   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits take steps to ensure that contracting officer’s representatives with oversight responsibilities for the Medical Disability Examination contracts achieve the VA-required certification level.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-03250-130 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees during the period from January 1, 2012, through December 31, 2017, and issue refunds.

No. 2   to Veterans Benefits Administration (VBA)

Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees prior to January 1, 2012, and issue refunds.

No. 3   to Veterans Benefits Administration (VBA)

Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to mitigate the lack of real-time funding fee exemption status updates through system enhancements or procedural changes that minimize inappropriate funding fee charges.

No. 4   to Veterans Benefits Administration (VBA)

Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to conduct periodic reviews to identify exempt veterans charged funding fees from January 1, 2018, forward, and issue refunds in a timely manner.

No. 5   to Veterans Benefits Administration (VBA)

Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to consistently obtain documentation and verify lenders apply funding fee refunds to veterans’ loan balances in a timely manner.

Total Monetary Impact of All Recommendations

Open: $ 352,600,000.00
Closed: $ 0.00

| 18-05864-127 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health implement steps to achieve stated reduction targets for the following programs and activities: Communications, Utilities, and Other Rent; Medical Care Contracts and Agreements; and State Home Per Diem.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-04669-125 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and then monitors the managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.

No. 3   to Veterans Health Administration (VHA)

The chief of staff ensures that clinical managers clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors the clinical managers’ compliance.

No. 4   to Veterans Health Administration (VHA)

The chief of staff ensures providers complete initial evaluations within the required timeframe for all new patients referred for mental health services for military sexual trauma and monitors the providers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the potential interactions and side effects of newly prescribed medications and monitors the clinicians’ compliance.

No. 6   to Veterans Health Administration (VHA)

The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors the clinicians’ compliance.

No. 7   to Veterans Health Administration (VHA)

The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.

No. 8   to Veterans Health Administration (VHA)

The facility director makes certain that the urgent care center is staffed with registered nurses in accordance with VHA policy at all times of operation and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-05130-105 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits works with the VA Secretary and Chief Financial Officer to take steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for funds already obligated and expended for medical examinations under the Decision Ready Claims program.

Total Monetary Impact of All Recommendations

Open: $ 10,572,000.00
Closed: $ 0.00

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