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

OIG Reports

| 19-06378-73 | Summary | Report

Recommendations (18)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director takes steps to ensure sufficient staffing to provide gender-specific care by designated women’s health primary care providers.

No. 2   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director ensures steps are taken to reduce panel sizes of designated women’s health primary care providers as required by Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director reviews the Veterans Health Administration policy recommended extended appointment times for comprehensive women veterans healthcare examinations and takes action as appropriate to achieve compliance.

No. 4   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director takes steps to ensure that appropriate resources, such as equipment, supplies, and space, are adequate to support comprehensive women veterans healthcare.

No. 5   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director takes steps to ensure that the Women Veterans Program Manager participates in the environment of care rounds and monitors for compliance with Veterans Health Administration policy.

No. 6   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director evaluates clinic areas where gender specific primary care is currently provided and when planning renovations to existing areas to ensure adequate restroom access for women veterans and takes action as appropriate.

No. 7   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director continues to evaluate and support staffing changes in the gynecology specialty clinic to enhance services.

No. 8   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director ensures implementation of an effective tracking mechanism to ensure VA providers receive results for women veterans referred to care in the community and monitors for compliance with Veterans Health Administration policy.

No. 9   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director verifies review of the electronic health records of women veterans referred to Care in the Community whose medical records have not been obtained and takes action if indicated.

No. 10   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director takes steps to ensure performance and evaluation processes provide the intended assessment of compliance with Veterans Health Administration requirements and monitors for compliance.

No. 11   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director verifies that institutional disclosures are conducted for events that meet disclosure criteria and monitors for compliance with Veterans Health Administration policy.

No. 12   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director takes steps to ensure the required number of combined totals of root cause analyses and aggregated reviews are completed, and monitors for compliance with Veterans Health Administration policy.

No. 13   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director ensures completion of root cause analyses within the required timeframes and monitors for compliance with Veterans Health Administration policy.

No. 14   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director verifies that staff complete training on policy related to high-risk patient goals of care conversations for life-sustaining treatment plans and monitors for completion of training.

No. 15   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director ensures staff conduct high-risk patient goals of care conversations for life-sustaining treatment plans as required and monitors for compliance with Veterans Health Administration policy.

No. 16   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director takes steps to ensure provider documentation of high-risk patient goals of care and life-sustaining treatment plan in the required electronic health record template and monitors for compliance with Veterans Health Administration policy.

No. 17   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director verifies capture and reporting of all codes to the resuscitation subcommittee and monitors for compliance with Veterans Health Administration policy.

No. 18   to Veterans Health Administration (VHA)

The VA North Texas Health Care System Director ensures that the Critical Care Committee minutes reflect corrective action plans and follow-through to remediate concerns identified by the resuscitation subcommittee and monitors for compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-07070-75 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Bath VA Medical Center Director ensures that surrogate providers comply with the facility’s notification policy when providing coverage.

No. 2   to Veterans Health Administration (VHA)

The Bath VA Medical Center Director ensures that the Bath VA Medical Center Patient Transfer Policy clearly defines a process for outpatient transfers to a higher level of care utilizing facility paramedics.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-00711-42 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Cincinnati Veterans Affairs Medical Center director ensures the Cincinnati Education and Research for Veterans Foundation’s board of directors establishes policies that require responsible officials to verify adequate supporting documentation before approving expenditures.

No. 2   to Veterans Health Administration (VHA)

The Cincinnati Veterans Affairs Medical Center director ensures the Cincinnati Education and Research for Veterans Foundation’s board of directors, or responsible officials, approve reimbursements to the executive director.

No. 3   to Veterans Health Administration (VHA)

The Cincinnati VA Medical Center director establishes 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 Intergovernmental Personnel Act agreements prior to approving invoices for payment.

No. 4   to Veterans Health Administration (VHA)

The Cincinnati VA Medical Center director establishes procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.

Total Monetary Impact of All Recommendations

Open: $ 950,000.00
Closed: $ 0.00

| 18-05121-36 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Develop and implement a mechanism for VA facilities and their respective VA community care departments to routinely identify and exchange wait time data to help make decisions that reduce patient wait times.

No. 2   to Veterans Health Administration (VHA)

Routinely monitor the timeliness of each distinct stage of the community care consult process so Veterans Integrated Service Network 8 facilities can identify specific delays.

No. 3   to Veterans Health Administration (VHA)

Ensure facilities routinely monitor the Office of Community Care staffing tool and take appropriate actions to confirm actual staffing levels are sufficient to meet workloads in a timely manner.

No. 4   to Veterans Health Administration (VHA)

Ensure community care administrative staff are effectively cross-trained to carry out applicable administrative consult processing duties to streamline scheduling and authorizations, and implement a control to monitor whether facilities are processing community care consults in accordance with Office of Community Care guidance and recommendations.

No. 5   to Veterans Health Administration (VHA)

Develop and implement specific facility plans to address the backlog of open consults and the growing number of new consults.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00046-60 | Summary | Report

Recommendations (17)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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

No. 2   to Veterans Health Administration (VHA)

The chief of staff ensures that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.

No. 3   to Veterans Health Administration (VHA)

The chief of staff confirms clinical staff responding to resuscitation events have basic or advanced cardiac life support certification and monitors clinical staff compliance.

No. 4   to Veterans Health Administration (VHA)

The chief of staff ensures service chiefs include defined time frames in focused professional practice evaluations and monitors service chiefs’ compliance.

No. 5   to Veterans Health Administration (VHA)

The chief of staff confirms that service chiefs ensure that focused professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.

No. 6   to Veterans Health Administration (VHA)

The chief of staff makes certain service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.

No. 7   to Veterans Health Administration (VHA)

The chief of staff confirms that service chiefs ensure that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.

No. 8   to Veterans Health Administration (VHA)

The chief of staff makes certain that service chiefs clearly define and share in advance with providers the time frame, expectations, and outcomes for focused professional practice evaluations for cause that do not limit providers’ ability to practice independently for more than 30 days and monitors service chiefs’ compliance.

No. 9   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. 10   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. 11   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. 12   to Veterans Health Administration (VHA)

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

No. 13   to Veterans Health Administration (VHA)

The facility director ensures that the facility has a full-time women veterans program manager.

No. 14   to Veterans Health Administration (VHA)

The chief of staff confirms that the Women Veterans Health Committee includes required core members and reports to a clinical executive level committee and monitors the committee’s compliance.

No. 15   to Veterans Health Administration (VHA)

The chief of staff ensures that program managers implement a process to track and monitor cervical cancer screenings and follow-up care and monitors program managers’ compliance.

No. 16   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. 17   to Veterans Health Administration (VHA)

The chief of staff ensures the chief of Social Work maintains a backup call schedule for emergency department social workers.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00034-62 | Summary | Report

Recommendations (13)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors for compliance.

No. 2   to Veterans Health Administration (VHA)

The facility director ensures that facility leaders review a Patient Safety Annual Report at the end of the fiscal year and monitors the patient safety manager’s compliance.

No. 3   to Veterans Health Administration (VHA)

The chief of staff ensures that the Code Blue/Rapid Response Team Committee reviews each resuscitative episode and monitors committee compliance.

No. 4   to Veterans Health Administration (VHA)

The facility director ensures that the controlled substance coordinator provides the monthly summary of findings and quarterly trends report to the director and monitors the controlled substance coordinator’s compliance.

No. 5   to Veterans Health Administration (VHA)

The facility director makes certain that the Quality Executive Board reviews the controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.

No. 6   to Veterans Health Administration (VHA)

The facility director makes certain that the controlled substances coordinator performs and documents competency assessments of the controlled substance inspectors annually and monitors controlled substances coordinator’s compliance.

No. 7   to Veterans Health Administration (VHA)

The facility director makes certain the controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors the inspectors’ compliance.

No. 8   to Veterans Health Administration (VHA)

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

No. 9   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 monitors the clinicians’ compliance.

No. 10   to Veterans Health Administration (VHA)

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

No. 11   to Veterans Health Administration (VHA)

The facility director ensures that urgent care center patients are assigned the appropriate stop codes to capture correct patient workload, productivity, and level of service and monitors compliance.

No. 12   to Veterans Health Administration (VHA)

The chief of staff ensures that a written provider staffing contingency plan and backup call schedule are maintained for urgent care center providers and monitors compliance.

No. 13   to Veterans Health Administration (VHA)

The facility director confirms that the urgent care center implements the Emergency Department Integration Software tracking program and transmits data to the Emergency Medicine Management Tool and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-06863-69 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The network director makes certain that the quality, safety, and value committee meets at least quarterly.

No. 2   to Veterans Health Administration (VHA)

The network director ensures the quality, safety, and value committee analyzes and reviews aggregated quality, safety, and value data.

No. 3   to Veterans Health Administration (VHA)

The network director makes certain that the quality management officer collects, analyzes, and acts upon Veterans Integrated Service Network peer review summary data as appropriate and monitors the quality management officer’s compliance.

No. 4   to Veterans Health Administration (VHA)

The chief medical officer confirms that facility service chiefs clearly define focused professional practice evaluation criteria in advance with licensed independent practitioners and monitors facility service chiefs’ compliance.

No. 5   to Veterans Health Administration (VHA)

The chief medical officer confirms that facility service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors clinical managers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The network director makes certain that the Veterans Integrated Service Network safety and network emergency management committee sends an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement to leadership for review and approval and monitors the committee’s compliance.

No. 7   to Veterans Health Administration (VHA)

The quality management officer reviews Veterans Integrated Service Network facilities’ controlled substances inspection quarterly trend reports.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00012-51 | Summary | Report

Recommendations (13)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The chief of staff ensures the Executive Committee of the Medical Staff reviews quarterly Peer Review Committee summary reports with trends and analysis of aggregate data and monitors the committee’s 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 facility director makes sure the patient safety manager includes a review of relevant literature in the root cause analysis and monitors the patient safety manager’s compliance.

No. 4   to Veterans Health Administration (VHA)

The facility director confirms that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and monitors the committee’s compliance.

No. 5   to Veterans Health Administration (VHA)

The facility director ensures that clinical managers implement corrective actions and monitor for effectiveness when problems or opportunities for improvement are identified and monitors the clinical managers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The chief of staff confirms that clinical service chiefs clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause that do not restrict the providers’ ability to practice independently for more than 30 days with providers and monitors the clinical service chiefs’ compliance.

No. 7   to Veterans Health Administration (VHA)

The associate director assures managers remove damaged wheelchairs from service and send them for repair or replacement and monitors managers’ compliance.

No. 8   to Veterans Health Administration (VHA)

The facility director makes certain that the facility quality manager ensures the Clinical and Performance Board reviews the monthly and quarterly controlled substance inspection program reports at least quarterly and monitors the quality manager’s compliance.

No. 9   to Veterans Health Administration (VHA)

The facility director makes certain that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses of controlled substances and monitors inspectors’ compliance.

No. 10   to Veterans Health Administration (VHA)

The facility director ensures that a pharmacist reviews the Omnicell® override report for appropriateness and frequency as required and monitors the pharmacist’s compliance.

No. 11   to Veterans Health Administration (VHA)

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

No. 12   to Veterans Health Administration (VHA)

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

No. 13   to Veterans Health Administration (VHA)

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

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00021-41 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Develop a mechanism to assess whether staffing levels within sleep medicine programs are sufficient for monitoring sleep apnea device use and conducting follow-ups with veterans.

No. 2   to Veterans Health Administration (VHA)

Ensure the Veterans Health Administration is leveraging existing technologies to make sure medical facilities are routinely monitoring veteran use of sleep apnea devices in a consistent and effective manner to more promptly identify individuals at risk of noncompliance with recommended therapies.

No. 3   to Veterans Health Administration (VHA)

Coordinate with the appropriate offices and services, including the Office of Procurement, Acquisitions, and Logistics, Prosthetic and Sensory Aids Service, sleep medicine, and the Veterans Health Administration National Infectious Diseases Service, to (a) assess the viability, potential patient care, and financial impact of an alternative to purchasing sleep apnea devices; (b) make and provide clear guidance on any changes to current Veterans Health Administration processes, including device returns, cleaning, and reissuance; and (c) designate an office with authority to ensure medical facilities implement any processes and recommendations from the assessment.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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1/25/2020 7:59:09 AM


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