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

OIG Reports

| 21-00299-162 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures that leaders identify adverse events as sentinel events when criteria are met.

No. 2   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures that leaders conduct institutional disclosures for all sentinel events.

No. 3   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days or approves a written extension request.

No. 4   to Veterans Health Administration (VHA)

The Executive Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.

No. 5   to Veterans Health Administration (VHA)

The Executive Chief of Staff and Associate Director, Patient Services evaluate and determine any additional reasons for noncompliance and ensure that appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note in the electronic health record prior to patient transfers.

No. 6   to Veterans Health Administration (VHA)

The Executive Chief of Staff and Associate Director, Patient Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.

No. 7   to Veterans Health Administration (VHA)

The Executive Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents decisions to implement Orders of Behavioral Restriction and patients’ notification of the orders in the Disruptive Behavior Reporting System.

No. 8   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required Prevention and Management of Disruptive Behavior training based on the risk level assigned to their work areas.

| 21-00295-161 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Staff attends Facility Surgical Work Group meetings.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Facility Surgical Work Group reviews National Surgery Office surgical quality reports.

No. 3   to Veterans Health Administration (VHA)

The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note to include required elements in the electronic health record prior to patient transfers.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.

No. 7   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between the sending and receiving facility.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure the Prevention and Management of Disruptive Behavior Program representative attends Disruptive Behavior Committee meetings.

No. 9   to Veterans Health Administration (VHA)

The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the annual Workplace Behavioral Risk Assessment includes participation by VA police and a patient safety representative.

No. 10   to Veterans Health Administration (VHA)

The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

| 21-00846-104 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Maximize opportunities to bill veterans’ private health insurers for recoverable claims by developing procedures that align and prioritize the processing of such claims to insurers’ filing deadlines.

No. 2   to Veterans Health Administration (VHA)

Strengthen information system controls to make certain that complete and accurate claims information is transferred between applicable current and future Community Care payment systems and the Consolidated Patient Account Centers’ workflow tool and VistA patient treatment files.

No. 3   to Veterans Health Administration (VHA)

Conduct an assessment to determine if staffing resources and workload are sufficiently aligned to process the anticipated volume of claims to be billed to veterans’ private health insurers and make adjustments as needed.

Total Monetary Impact of All Recommendations

Open: $ 805,200,000.00
Closed: $ 0.00

| 21-01820-159 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VISN 23 Director ensures implementation and sustainment of initial and annual home visits for patients accepted into the VISN 23 home dialysis program.

No. 2   to Veterans Health Administration (VHA)

The VISN 23 Director ensures the implementation and sustainment of quality monitoring of contracted clinical services for home dialysis.

No. 3   to Veterans Health Administration (VHA)

The VISN 23 Director ensures that VA providers receive mammography reports from non-VA providers within the established acceptable timeframe.

| 21-01048-154 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director reviews the primary care provider’s care of the patient in the year prior to surgery and takes action as indicated.

No. 2   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures patient aligned care team nurses are aware of and comply with the Veterans Health Administration patient aligned care team policy including requirements for same-day access.

No. 3   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures patient aligned care team physicians are aware of and comply with the Veterans Health Administration directive regarding communication of test results to patients including time frames and communication of associated treatment plans.

No. 4   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures that surrogates are assigned for patient aligned care team nurses while they are on leave.

No. 5   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director reviews the patient’s preoperative care, including additional quality reviews, and takes action as indicated.

No. 6   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director reviews medical-surgical unit nurses’ care of the patient and takes action as warranted.

No. 7   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director evaluates the use of the Trendelenburg position in inpatient areas and provides education to all facility nursing staff on the potential risks of and indications for use.

No. 8   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures that all medical-surgical unit nurses demonstrate competency to provide adequate alcohol withdrawal care and monitors for compliance.

No. 9   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director implements controls to ensure care provided by medical-surgical unit nurses is of an acceptable quality.

No. 10   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures that the Charlie Norwood VA Medical Center alcohol withdrawal treatment protocol is specific, does not conflict with physicians’ orders, and aligns with the probable onset of patients’ alcohol withdrawal symptoms.

| 21-03525-148 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures urgent care providers, chiropractors, and clinical massage therapists are educated on consult processes and procedures and the requirement of timely documentation.

No. 2   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director conducts an internal review of the Complementary and Alternative Medicine Program processes related to patient care including receiving and reviewing consults, scheduling appointments, checking-in patients for care, and documentation.

| 21-00533-157 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   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.

| 18-04227-91 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of the Secretary

We recommend that the Deputy Secretary of Defense and Deputy Secretary of Veterans Affairs review the actions of the Federal Electronic Health Record Modernization Program Office and direct the Federal Electronic Health Record Modernization Program Office to develop processes and procedures in accordance with the Federal Electronic Health Record Modernization Program Office charter and the National Defense Authorization Acts.

No. 2   to Electronic Health Record Modernization Integration Office

We recommend that the Director of the Federal Electronic Health Record Modernization Program Office, in coordination with the Director of the Defense Health Agency; Program Executive Director for Electronic Health Record Modernization Integration; and Program Manager for DoD Healthcare Management System Modernization: a. Determine the type of patient health care information that constitutes a complete patient electronic health record. b. Develop and implement a plan for migrating legacy patient health care information needed for a patient’s complete electronic health record once the Federal Electronic Health Record Modernization Program Office determines the health care data domains of patient health care information that constitutes a complete patient electronic health record. c. Develop and implement a plan for creating interfaces that would allow medical devices to connect and transfer patient health care information to Cerner Millennium.

Supplemental InformationToggle Content

Acknowledgements and Distribution Page

Additional information on IG Contact and Staff Acknowledgements and Report Distribution

| 21-00296-145 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality Leadership Council.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends individual improvement actions, and clinical managers implement the committee’s recommendations.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days from the date it is determined a peer review is required or have a written extension request approved by the Director.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits quarterly summaries of peer review data for review by the Executive Committee of the Medical Staff.

No. 5   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets at least monthly.

No. 6   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain all inter-facility transfers are monitored and evaluated as part of the Veterans Health Administration’s Quality Management Program.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.

| 21-00300-130 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff conduct a peer review for all applicable deaths that occur within 24 hours of admission.

No. 2   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses at the time of initial application.

No. 3   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.

No. 5   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

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