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

OIG Reports

| 18-06504-27 | Summary | Report

Recommendations (14)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The chief of staff ensures that clinicians peer review all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.

No. 2   to Veterans Health Administration (VHA)

The chief of staff verifies that clinicians complete peer reviews of all completed suicides that occur within seven days after discharge from inpatient mental health treatment or residential care units and monitors clinicians’ compliance.

No. 3   to Veterans Health Administration (VHA)

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

No. 4   to Veterans Health Administration (VHA)

The associate director ensures electronic safety data sheets are readily accessible to employees and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

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

No. 6   to Veterans Health Administration (VHA)

The associate director ensures the mental health nursing station prevents unauthorized entry and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The associate director ensures that the hazard vulnerability analysis and the emergency operations plan are approved by executive leadership and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The facility director ensures that controlled substances inspection program staff complete reconciliation of one random day’s return of stock to the pharmacy from every automated dispensing cabinet during monthly inspections and monitors program staff compliance.

No. 9   to Veterans Health Administration (VHA)

The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.

No. 10   to Veterans Health Administration (VHA)

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

No. 11   to Veterans Health Administration (VHA)

The chief of staff ensures clinicians reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.

No. 12   to Veterans Health Administration (VHA)

The chief of staff makes certain that the Women Veterans Health Committee includes all required core members and monitors the committee’s compliance.

No. 13   to Veterans Health Administration (VHA)

The chief of staff ensures the Women Veterans Health Committee reports to executive leaders and monitors the committee’s compliance.

No. 14   to Veterans Health Administration (VHA)

The chief of staff makes certain that the emergency department director maintains a backup call schedule for emergency department providers and monitors the director’s compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00024-39 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The chief medical officer ensures that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The facility director makes certain that controlled substances inspectors perform a complete count of the pharmacy’s controlled substances physical inventory during monthly inspections and monitors inspectors’ compliance.

No. 3   to Veterans Health Administration (VHA)

The chief medical officer ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with facility leaders and monitors coordinator’s compliance.

No. 4   to Veterans Health Administration (VHA)

The chief medical officer makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data.

No. 5   to Veterans Health Administration (VHA)

The chief medical officer ensures providers complete comprehensive diagnostic evaluations within the required time frame for all new patients referred for mental health services for military sexual trauma and monitors providers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The chief medical officer makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.

No. 7   to Veterans Health Administration (VHA)

The chief medical officer ensures clinicians review and reconcile medications and monitors clinicians’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-06562-30 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Medical 15 Facility Director conducts an evaluation of radiation oncology clinic mental health consultation and treatment program needs and adjusts mental health provider coverage as warranted.

No. 2   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Medical 15 Facility Director ensures that all components of the oncology service psychosocial distress screening standard operating procedures include screening frequency consistent with National Comprehensive Cancer Network’s ideal standards.

No. 3   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Medical 15 Facility Director guarantees that the patient safety program maintains effective processes to track action items to completion and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Medical 15 Facility Director ensures that staff complete Suicide Behavior and Overdose Reports and Behavioral Health Autopsies, as required by the Veterans Health Administration.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-02300-236 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Ensure facility staff evaluate scheduling workload and that medical support assistant staffing is adequately distributed for scheduling radiology exam requests in a timely manner.

No. 2   to Veterans Health Administration (VHA)

Provide formal guidance to facilities for establishing clinic management models for adequate radiology resources, including staffing and equipment.

No. 3   to Veterans Health Administration (VHA)

Ensure facility radiology and nuclear medicine services monitor exam requests pending greater than seven days and address them in a timely manner.

No. 4   to Veterans Health Administration (VHA)

Confirm with each facility director that they reviewed each record and took appropriate action as they deemed necessary for the three completed requests with additional follow-up care needs.

No. 5   to Veterans Health Administration (VHA)

Develop and implement a plan for improved radiology and nuclear medicine oversight at the Veterans Integrated Service Network level.

No. 6   to Veterans Health Administration (VHA)

Implement a mechanism to routinely audit canceled exam requests, ensuring the requests are in accordance with VA radiology and nuclear medicine policies and procedures for canceling exam requests, and taking corrective actions as needed based on audit results.

No. 7   to Veterans Health Administration (VHA)

Create a method to notify radiology and nuclear medicine leaders at all VA medical facilities when guidance is released. The method should be streamlined with maximum distribution and ensure receipt and acknowledgment by affected radiology and nuclear medicine leaders.

No. 8   to Veterans Health Administration (VHA)

Confirm with each facility director that they review each record and take appropriate action for five of the six canceled requests with outstanding exam needs.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00049-43 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The chief of staff ensures that the Medical Executive Committee considers and documents the deliberation of professional practice data prior to granting privileges and monitors committee’s compliance.

No. 2   to Veterans Health Administration (VHA)

The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.

No. 3   to Veterans Health Administration (VHA)

The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided and monitors clinicians’ compliance.

No. 4   to Veterans Health Administration (VHA)

The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.

No. 5   to Veterans Health Administration (VHA)

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

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00014-33 | Summary | Report

Recommendations (20)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ 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 representatives’ compliance.

No. 3   to Veterans Health Administration (VHA)

The facility director ensures all root cause analyses actions are fully implemented by assigned staff and monitors the assigned staff’s compliance.

No. 4   to Veterans Health Administration (VHA)

The facility director ensures the Cardiopulmonary Resuscitation Committee conducts complete analyses of resuscitative episodes by reviewing required elements and monitors the committee’s compliance.

No. 5   to Veterans Health Administration (VHA)

The chief of staff makes certain that the Radiology Service chief includes the required nuclear medicine-specific criteria for ongoing professional practice evaluations of nuclear medicine providers and monitors the chief’s compliance.

No. 6   to Veterans Health Administration (VHA)

The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.

No. 7   to Veterans Health Administration (VHA)

The facility director makes certain that controlled substances program staff complete reconciliation of one random day’s return of stock to pharmacy from every automated dispensing cabinet during inspections and monitors controlled substances program staff compliance.

No. 8   to Veterans Health Administration (VHA)

The facility director ensures controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.

No. 9   to Veterans Health Administration (VHA)

The facility director ensures that the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training.

No. 10   to Veterans Health Administration (VHA)

The facility director makes certain that the military sexual trauma coordinator establishes and monitors informational outreach and monitors the coordinator’s compliance.

No. 11   to Veterans Health Administration (VHA)

The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with leadership and monitors the coordinator’s compliance.

No. 12   to Veterans Health Administration (VHA)

The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.

No. 13   to Veterans Health Administration (VHA)

The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.

No. 14   to Veterans Health Administration (VHA)

The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.

No. 15   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 records and monitors clinicians’ compliance.

No. 16   to Veterans Health Administration (VHA)

The facility director ensures the Women Veterans Health Committee maintains an active charter, meets at least quarterly, and reports to executive leaders with signed minutes and monitors the committee’s compliance.

No. 17   to Veterans Health Administration (VHA)

The chief of staff confirms that the women veterans program manager implements a quality assurance process to include tracking of data for cervical cancer screening and results and monitors the manager’s compliance.

No. 18   to Veterans Health Administration (VHA)

The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.

No. 19   to Veterans Health Administration (VHA)

The chief of staff directs the acute care medical director to ensure that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.

No. 20   to Veterans Health Administration (VHA)

The facility director makes certain that the chief of Pharmacy ensures highly concentrated oral liquid opioid medications are not stored in patient care areas for patient safety and monitors the chief’s compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00019-26 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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

No. 2   to Veterans Health Administration (VHA)

The chief of staff ensures that the imaging service chief includes the minimum required specialty-specific criteria for focused professional practice evaluations of nuclear medicine practitioners and monitors imaging service chief’s compliance.

No. 3   to Veterans Health Administration (VHA)

The associate director confirms that facility managers replace or remove damaged furnishings and wheelchairs from service and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The facility director makes certain that the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substance orders and monitors inspectors’ compliance.

No. 5   to Veterans Health Administration (VHA)

The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The chief of staff makes certain that clinicians provide and document patient and/or caregivers education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.

No. 7   to Veterans Health Administration (VHA)

The facility director ensures the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.

No. 8   to Veterans Health Administration (VHA)

The facility director makes certain that the emergency department is staffed with a minimum of two registered nurses during all hours of operation and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-00711-211 | Summary | Report | Redacted

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA); Office of General Counsel (OGC)

The under secretary for health confer with VA Office of General Counsel and the VA Boston Healthcare System Human Resources Office to determine if administrative actions should be taken concerning VA Boston Healthcare System officials responsible for the $1.6 million in inappropriate payments to the Boston VA Research Institute.

No. 2   to Veterans Health Administration (VHA)

The under secretary for health determine appropriate actions for the inappropriate overpayments, made by VA Boston Healthcare System officials, associated with salaries and fringe benefits for ineligible Boston VA Research Institute administrative staff, as well as duplicate employer retirement contribution payments.

No. 3   to Veterans Health Administration (VHA)

The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Human Resources Office develops procedures to require reviews of VA-affiliated nonprofit corporation Intergovernmental Personnel Act agreements for compliance with VA Handbook 5005, Staffing, prior to approval.

No. 4   to Veterans Health Administration (VHA)

The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Research and Development Budget Office develops procedures for adequate review of VA-affiliated nonprofit corporation invoices to prevent duplicate payments in accordance with VA financial policy prior to approval.

No. 5   to Veterans Health Administration (VHA)

The VA Boston Healthcare System director determine appropriate actions to ensure procedures are developed that require the VA Boston Healthcare System Research and Development Budget Office supervisor to conduct periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.

No. 6   to Veterans Health Administration (VHA)

The VA Boston Healthcare System director establish procedures to ensure research and development budget office staff review VA-affiliated nonprofit corporation invoices to make certain services were performed or the goods have been received in accordance with the agreement prior to payment.

No. 7   to Veterans Health Administration (VHA)

The VA Boston Healthcare System director establish procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff to prevent improper payments, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Filter Options

Use the controls below to filter the list of OIG reports. Click on the headings to view the filter choices.

Current Filter

  • All records

12/13/2019 9:51:03 AM


Date RangeRemove

Limits the list of reports to those published in the date range specified below.

Report LocationRemove

Limits the list of reports to those pertaining to the cities selected below. Hold down the control key to select multiple values or to toggle an individual value on or off.

VA Administration/Staff OfficeRemove

Limits the list of reports to those pertaining to the VA offices selected below. Hold down the control key to select multiple values or to toggle an individual value on or off.

Report TypeRemove

Limits the list of reports to the report types selected below. Hold down the control key to select multiple values or to toggle an individual value on or off. For a description of the types of reports published by the OIG, please visit our Reports and Publications homepage.

OIG Report AuthorRemove

Limits reports to those authored by specific OIG elements.

Report NumbersRemove

Helpful for finding reports if you know the report number. Separate multiple values with semicolons.

Search TermsRemove

Limit the results to reports that match your search terms.

Recommendation StatusRemove

Limits reports to those with open or closed recommendations.

Recommendation Action OfficeRemove

Limits reports to those with recommendations specific to the following VA Offices

Displaying records at a time.