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

OIG Reports

| 21-03195-189 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director ensures that facility practice is consistent with Veterans Health Administration and facility policy applicable to early refills of buprenorphine for patients receiving opioid agonist therapy for opioid use disorder and is consistent with evidence-based treatment and prescribing providers’ clinical rationale, ensures all relevant staff are educated on the policy, and monitors for compliance with policy.

No. 2   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director ensures communication between provider, pharmacist, and patient for early medication refills and monitors for compliance with Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director clarifies the roles and responsibilities of the Opioid Safety Committee as related to buprenorphine treatment for patients with opioid use disorder, and ensures relevant staff are educated regarding the Opioid Safety Committee’s role in buprenorphine treatment.

No. 4   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director reviews buprenorphine prescribing provider concerns regarding the Opioid Agonist Therapy (Buprenorphine) for Opioid Use Disorder standard operating procedure and ensures the planned revision and implementation of the standard operating procedure is consistent with evidence-based treatment and includes language that specifies allowance for clinical judgment and a patient-centered care approach.

No. 5   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director reviews prescribing provider staffing levels in accordance with the Substance Use Disorder program’s needs and facility’s plans for expanding buprenorphine treatment in other clinical areas, and develops an action plan to address recommendations, if any, from the staffing level review.

| 21-03201-185 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director provides oversight of the purchase and installation of an electronic alarm system for all Community Living Center neighborhoods and cottages and confirms ongoing monitoring of its use after installation.

No. 2   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director confirms completion of the risk analysis recommended in the facility-initiated risk assessment to determine if the Azalea House is suitable for the patient population residing there.

No. 3   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director ensures that all security cameras are operable and labeled appropriately and develops and monitors a plan for ongoing testing and maintenance.

No. 4   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director directs staff to assess the effectiveness of the outdoor fencing and gates surrounding Azalea House as a security measure to prevent Community Living Center residents at-risk for elopement from leaving the facility campus.

No. 5   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director establishes a review process to ensure that Community Living Center residents determined to be high risk for elopement have documentation consistent with Tuscaloosa VA Medical Center policy in their electronic health records identifying residents’ risk status.

No. 6   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director collaborates with the Veterans Integrated Service Network 7 Senior Strategic Business Partner to determine difficult to fill job series and develops a plan to maximize use of available tools for coverage, recruitment, and retention.

No. 7   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director ensures completion of a review of the facility’s Comprehensive Environment of Care program to confirm that patient care areas are properly classified, all areas are inspected at the required frequency, and compliance is monitored.

No. 8   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director coordinates with subject matter experts and develops a plan to ensure that the facility’s Comprehensive Environment of Care program effectively identifies areas in need of attention to provide a clean and safe environment for patients, visitors, and staff.

No. 9   to Veterans Health Administration (VHA)

The Tuscaloosa VA Medical Center Director confirms that Engineering Service staff conduct rounds of the grounds according to Tuscaloosa VA Medical Center policy.

No. 10   to Veterans Health Administration (VHA)

The VA Southeast Network 7 Director ensures completion of the Tuscaloosa VA Medical Center’s action plan to address recommendations made as a result of the October 2021 Veterans Integrated Service Network site visit.

| 21-03349-186 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that providers communicate, act on, and document a review of test results consistent with Veterans Health Administration policy.

No. 2   to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director determines why the abnormal prostate-specific-antigen test results were not alerted to an ordering or surrogate provider and if other patient test results during that time frame also warrant review.

No. 3   to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.

No. 4   to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.

No. 5   to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that procedures are in place to identify and reduce errors when staff place nuclear medicine orders.

No. 6   to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that facility staff submit patient safety reports consistent with Veterans Health Administration and Hampton VA Medical Center policy

No. 7   to Veterans Health Administration (VHA)

The Hampton VA Medical Center Director ensures that quality management staff initiate timely quality reviews when deficiencies in patient care are identified.

| 22-00576-178 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The acting under secretary for health take necessary measures to reduce improper and unknown payments to below 10 percent for Beneficiary Travel, Medical Care Contracts and Agreements, Purchased Long-Term Services and Supports, and VA Community Care programs and activities.

| 21-03080-142 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Information and Technology (OIT)

The OIG recommends the Assistant Secretary for Information and Technology develop controls to help ensure minor applications are not misclassified as assets and undergo the appropriate security accreditation and certification process.

No. 2   to Office of Information and Technology (OIT); Veterans Benefits Administration (VBA)

The OIG recommends the Assistant Secretary for Information and Technology in conjunction with the Under Secretary for Benefits, make certain that appropriate security and privacy controls are implemented during the development of information technology systems before being hosted on VA’s network.

No. 3   to Office of Information and Technology (OIT); Veterans Benefits Administration (VBA)

The OIG recommends the Under Secretary for Benefits, in conjunction with the Assistant Secretary for Information and Technology, establish a mechanism to gain assurance that proper Office of Information Technology project management processes and protocols are followed when establishing information technology systems and applications.

No. 4   to Veterans Benefits Administration (VBA)

The OIG recommends the Under Secretary for Benefits establish policies and procedures to ensure the Mission Accountability Support Tracker is used appropriately and does not contain unnecessary personally identifiable information.

| 21-00288-175 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met and conduct institutional disclosures as required.

No. 2   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.

No. 3   to Veterans Health Administration (VHA)

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

No. 4   to Veterans Health Administration (VHA)

The Associate Director, Clinical Services evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.

No. 5   to Veterans Health Administration (VHA)

The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine reasons for noncompliance and ensure staff monitor and evaluate all inter-facility transfers as part of VHA’s Quality Management Program.

No. 6   to Veterans Health Administration (VHA)

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

No. 7   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team meetings are held and members complete training, as required.

No. 8   to Veterans Health Administration (VHA)

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

No. 9   to Veterans Health Administration (VHA)

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

| 21-00283-173 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines additional reasons for noncomplianceand ensures that peer reviewers use at least one of the nine aspects of care forevaluations.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures that the Peer Review Committee recommendsimprovement actions for Level 3 peer reviews.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons fornoncompliance and makes certain that the Peer Review Committee completes finalpeer reviews within 120 calendar days from the date it is determined a peer reviewis required, or the System Director approves any necessary extensions in writing.

No. 4   to Veterans Health Administration (VHA)

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

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders complete all elements of the VA Inter-Facility Transfer Form or afacility-defined equivalent note in the electronic health record.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders 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 anyadditional reasons for noncompliance and makes certain that nurse-to-nursecommunication occurs between sending and receiving facilities.

No. 8   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons fornoncompliance and ensures employees complete all required prevention andmanagement of disruptive behavior training based on the risk level assigned to theirwork area.

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