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

OIG Reports

| 21-03311-15 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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

| 21-00175-19 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures compliance with suicide risk and lethal means safety training requirements.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the efficacy of the May 2022 Veterans Integrated Service Network and Office of Mental Health and Suicide Prevention oversight structure for suicide risk training and considers inclusion of an oversight structure for lethal means safety training compliance.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the adequacy of the one-time lethal means safety training requirement and takes action as appropriate.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures clinician completion of comprehensive suicide risk evaluations including the discussion and documentation of firearms access and safe storage as required, and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures clinician completion of safety plans including the discussion and documentation of firearms access and safe storage, as applicable, and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates staff’s perceived barriers to completion of the suicide risk identification strategy and takes action as appropriate.

No. 7   to Veterans Health Administration (VHA)

The Under Secretary for Health considers initiatives to evaluate and address educational and cultural barriers to conducting and documenting patient discussions related to firearms access and safe storage practices.

| 21-03777-218 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Monitor facility follow-up rates by type of care and on a month-over-month basis, establish monitoring metrics, and assist facilities if they fall below these metrics.

No. 2   to Veterans Health Administration (VHA)

Evaluate and update, as appropriate, whether activities that occurred before cancellation and notations of “No Action Other Reason” should be tracked as follow-up.

| 21-01821-08 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VISN 15 Network Director ensures that an end-stage renal disease provider sees patients enrolled in the home dialysis program at least monthly, as evidenced by a progress note placed in the medical record and endorsed by the responsible independent renal practitioner.

No. 2   to Veterans Health Administration (VHA)

The VISN 15 Network Director makes certain that staff ensure home visits are performed prior to accepting patients into the home dialysis program, and at least annually thereafter.

No. 3   to Veterans Health Administration (VHA)

The VISN 15 Network Director ensures VISN leaders and clinicians monitor the quality of contracted clinical services for patients receiving non-VA home dialysis services.

| 22-01440-254 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Consider seeking legislative relief from Congress regarding the language related to reporting potential hires under the element of section 3008(a)(E)(iii) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.

No. 2   to Human Resources and Administration/Operations, Security, and Preparedness (HRA/OSP)

Absent such relief, provide information detailing the limitations that prevent VA from reporting the average number of days that potential title 38 or hybrid title 38 hires spent in each phase of the hiring model in accordance with section 3008(a)(E)(iii) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.

| 21-03924-234 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Assign specific roles and responsibilities to the Office of Integrated Veteran Care to ensure effective oversight of the Referral Coordination Initiative.

No. 2   to Veterans Health Administration (VHA)

Make certain that staff with Referral Coordination Initiative responsibilities are sufficiently trained on how to triage, communicate key information on options to veterans, schedule, or document consults, according to their respective duties.

No. 3   to Veterans Health Administration (VHA)

Direct relevant VA medical facilities to establish local processes by which VA medical facility staff identify and share available community care wait time data with referral coordination team members within each facility, and then establish controls to help ensure that this information is consistently communicated to patients.

No. 4   to Veterans Health Administration (VHA)

Establish a mechanism or update the Referral Coordination Initiative checklist to effectively track and monitor each facility’s challenges with implementation and progress toward implementing the initiative for all relevant specialty services.

No. 5   to Veterans Health Administration (VHA)

Develop and then disseminate to all relevant VA medical facilities best practices and lessons learned for implementing the Referral Coordination Initiative.

No. 6   to Veterans Health Administration (VHA)

Make sure that VA medical facility staff are completely and accurately tracking andmonitoring consults processed through the Referral Coordination Initiative using theConsult Toolbox 2.0 or the most current system and version.

No. 7   to Veterans Health Administration (VHA)

Develop measures and processes to assess whether facility staff are meeting the Referral Coordination Initiative’s intent of reducing scheduling times, providing veterans with key information, and minimizing facility providers’ administrative burden of managing consults.

| 22-00818-03 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility peer review committees recommend improvement actions for Level 3 peer reviews.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility surgical work groups meet monthly and core members consistently attend meetings.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility surgical work groups consistently review surgical deaths.

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