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

OIG Reports

| 19-06125-218 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA); Office of Information and Technology (OIT)

The assistant secretary for information and technology and the under secretary for benefits provide remedial training to users on the safe handling and storage of sensitive personal information on network drives.

No. 2   to Office of Information and Technology (OIT)

The assistant secretary for information and technology establishes technical controls to ensure users cannot store sensitive personal information on shared network drives.

No. 3   to Office of Information and Technology (OIT)

The assistant secretary for information and technology implements improved oversight procedures, including specific facility-level procedures, to ensure that sensitive personal information is not being stored on shared network drives.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-07040-243 | Summary | Report

Recommendations (16)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, ensure that clinical managers consistently implement improvement actions recommended from peer review activities and monitor clinical managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that physician utilization management advisors document the minimum required percentage of all inpatient stay reviews in the National Utilization Management Integration database and monitor physician advisors’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that an interdisciplinary group or committee, that includes all required representatives, consistently reviews utilization management data and monitor committees’ compliance.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that clinical managers provide feedback about root cause analysis actions to the individuals or departments who reported the incidents and monitor clinical managers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers report completed focused professional practice evaluations to an appropriate committee of the medical staff and monitor clinical managers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers clearly delineate time frames in focused professional practice evaluations and monitor clinical managers’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers include service-specific data in ongoing professional practice evaluations and monitor clinical managers’ compliance.

No. 8   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers include specialty-specific elements in gastroenterology, pathology, nuclear medicine, and radiation oncology providers’ ongoing professional practice evaluations and monitor clinical managers’ compliance.

No. 9   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that managers maintain a clean and safe environment throughout the facilities and monitor managers’ compliance.

No. 10   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that VA Police test panic alarms and document response times to alarm testing in locked mental health units and high-risk outpatient clinic areas and monitor VA Police compliance.

No. 11   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that facility managers install floor cushioning in locked mental health unit seclusion rooms and monitor facility managers’ compliance.

No. 12   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that facility managers annually review emergency operations plans and resource and asset inventories and monitor facility managers’ compliance.

No. 13   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that facility managers correct identified deficiencies from annual physical security surveys and monitor facility managers’ compliance.

No. 14   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that controlled substances coordinators reconcile one-day’s dispensing from the pharmacy to every automated dispensing cabinet and returns to pharmacy stock from each dispensing area during controlled substances inspections and monitor controlled substances coordinators’ compliance.

No. 15   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that controlled substances coordinators refrain from routinely conducting monthly controlled substances inspections and monitor controlled substances coordinators’ compliance.

No. 16   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network Directors and facility senior leaders, ensure that facility managers conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitor facility managers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-03979-204 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The under secretary for benefits implements controls to identify and address unreported monthly loan status in the upgraded VA Loan Electronic Reporting Interface system and implement compensating controls in the interim.

No. 2   to Veterans Benefits Administration (VBA)

The under secretary for benefits ensures that loan servicers report when loss mitigation letters are sent and impose necessary regulatory infractions when required.

No. 3   to Veterans Benefits Administration (VBA)

The under secretary for benefits ensures post-audit and adequacy of servicing reviews are compiled and trended and generate key loan servicer performance statistics.

No. 4   to Veterans Benefits Administration (VBA)

The under secretary for benefits develops a plan to implement a formal tier-ranking system following the implementation of the upgraded VA Loan Electronic Reporting Interface system.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-05316-234 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director verifies that facility managers adhere to Veterans Health Administration policy that outlines the credentialing and privileging process for licensed independent practitioners.

No. 2   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director and managers meet all requirements of state licensing boards reporting.

No. 3   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting of all adverse events to the Patient Safety Manager.

No. 4   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director confers with Human Resources regarding the actions taken by facility leaders and managers, related to the lack of oversight and failure to conduct credentialing and privileging per Veterans Health Administration requirements, and take administrative action(s) as necessary.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00346-241 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures completion of all open action plans related to recommendations from previous iterations of this report.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health identifies a plan of action that will address the underlying causes of severe occupational staffing shortages identified in this report.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-04679-239 | Summary | Report

Recommendations (21)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 advisors’ compliance

No. 2   to Veterans Health Administration (VHA)

The facility director confirms that the patient safety manager includes all required content in root cause analyses and monitors patient safety manager’s compliance.

No. 3   to Veterans Health Administration (VHA)

The facility director makes certain the Code Blue Committee reviews each resuscitative episode under the facility’s responsibility and monitors Code Blue Committee’s compliance.

No. 4   to Veterans Health Administration (VHA)

The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated criteria and time frames in advance and monitors clinical managers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The chief of staff ensures that focused professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The chief of staff makes certain that the Medical Professional Standards Committee reviews and evaluates licensed independent practitioners’ professional practice evaluations when recommending approval of privileges through the Medical Executive Council to the director and monitors committee’s compliance.

No. 7   to Veterans Health Administration (VHA)

The chief of staff ensures that service chiefs consistently collect and review ongoing professional practice evaluation data and monitors service chiefs’ compliance.

No. 8   to Veterans Health Administration (VHA)

The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The facility director makes certain that the controlled substance inspectors conduct the monthly inventories of controlled substances and the controlled substances coordinator maintains supporting documentation of the completion of the monthly inventory of controlled substances and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors compliance.

No. 11   to Veterans Health Administration (VHA)

The facility director makes certain that controlled substances inspectors complete the pharmacy monthly controlled substances inspection inventory on the day initiated and monitors inspectors’ compliance.

No. 12   to Veterans Health Administration (VHA)

The facility director makes certain that during monthly inspections, controlled substances inspectors verify that each medication listed on the “Destructions File Holding Report” is contained in a corresponding sealed evidence bag and monitors compliance of controlled substance inspection staff.

No. 13   to Veterans Health Administration (VHA)

The facility director ensures that controlled substances inspectors and coordinator carry out all responsibilities for the verification of pharmacy prescription pad counts during monthly pharmacy inspections and monitors controlled substances inspections staff compliance.

No. 14   to Veterans Health Administration (VHA)

The facility director ensures the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of written controlled substances prescriptions during monthly area inspections and monitors compliance.

No. 15   to Veterans Health Administration (VHA)

The facility director makes certain that controlled substances inspectors and coordinator carry out responsibilities for the 72-hour pharmacy inventory checks as required and monitors compliance.

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

The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors compliance.

No. 18   to Veterans Health Administration (VHA)

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

No. 19   to Veterans Health Administration (VHA)

The facility director makes certain that the women veterans program manager position is full time and monitors compliance.

No. 20   to Veterans Health Administration (VHA)

The chief of staff ensures the emergency department has an independent licensed mental health provider available as required for 1a facilities and monitors compliance.

No. 21   to Veterans Health Administration (VHA)

The chief of staff ensures that sufficient signage assists and directs patients in locating the emergency department and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00010-237 | Summary | Report

Recommendations (28)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The chief of staff ensures all required representatives participate in the interdisciplinary review of utilization management data and monitors representatives’ compliance.

No. 2   to Veterans Health Administration (VHA)

The facility director makes certain that the patient safety manager or designee includes all required components in each root cause analysis and monitors patient safety manager’s compliance.

No. 3   to Veterans Health Administration (VHA)

The facility director ensures that the identified committee reviews all resuscitative episodes and monitors the committee’s compliance.

No. 4   to Veterans Health Administration (VHA)

The chief of staff ensures that clinical managers clearly define focused professional practice evaluation criteria in advance with providers and monitors clinical managers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The chief of staff confirms that clinical managers include service/section-specific criteria in ongoing professional practice evaluations and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The chief of staff makes certain that service chiefs’ determination to recommend continuation of privileges be based in part on results of ongoing professional practice activities and monitors service chiefs’ compliance.

No. 7   to Veterans Health Administration (VHA)

The deputy director confirms that facility managers maintain a safe and clean environment throughout the healthcare system and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The deputy director ensures the furnishings in the intensive care units are repaired or replaced and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The deputy director makes certain that medical biohazardous waste storage rooms are secured and properly identified and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

The deputy director makes certain that facility management service managers conduct weekly generator testing as required and monitors managers’ compliance.

No. 11   to Veterans Health Administration (VHA)

The facility director makes certain that controlled substances inspectors complete the monthly controlled substances inspections and physical inventory counts on the day initiated and that the controlled substances coordinator evaluates and maintains supporting documentation and monitors inspectors’ and coordinator’s compliance.

No. 12   to Veterans Health Administration (VHA)

The facility director ensures controlled substances inspectors do not inspect the same area for two or more consecutive months and monitors inspectors’ compliance.

No. 13   to Veterans Health Administration (VHA)

The facility director makes certain the controlled substances coordinator ensures that written and electronic controlled substance orders have been verified and monitors coordinator’s compliance.

No. 14   to Veterans Health Administration (VHA)

The facility director ensures that controlled substances inspectors verify there is a corresponding sealed evidence bag containing drug(s) for each medication listed on the “Destructions File Holding Report” during monthly inspections and monitors inspectors’ compliance.

No. 15   to Veterans Health Administration (VHA)

The facility director ensures that controlled substances inspectors complete pharmacy prescription pad inventories during monthly pharmacy inspections and monitors inspectors’ compliance.

No. 16   to Veterans Health Administration (VHA)

The facility director ensures the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances orders during monthly area inspections and monitors inspectors’ compliance.

No. 17   to Veterans Health Administration (VHA)

The facility director makes certain that controlled substances inspectors complete the verification of the twice weekly pharmacy inventory as required and monitors inspectors’ compliance.

No. 18   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. 19   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 clinicians’ compliance.

No. 20   to Veterans Health Administration (VHA)

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

No. 21   to Veterans Health Administration (VHA)

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

No. 22   to Veterans Health Administration (VHA)

The facility director confirms that the Women Veterans Health Committee reports to an executive leadership committee and monitors the committee’s compliance.

No. 23   to Veterans Health Administration (VHA)

The chief of staff ensures that staff collect and track cervical cancer screening data and monitors staff compliance.

No. 24   to Veterans Health Administration (VHA)

The facility director makes certain that the emergency department has on-call social work staff available to assist with patient care and monitors staff compliance.

No. 25   to Veterans Health Administration (VHA)

The facility director confirms adequate directional signage leads patients to the emergency department and monitors staff compliance.

No. 26   to Veterans Health Administration (VHA)

The facility director ensures the chief of Health Information Management facilitates the timely scanning of clinical reports into patients’ electronic health records and monitors compliance.

No. 27   to Veterans Health Administration (VHA)

The deputy director ensures medical equipment is evaluated per manufacturers’ recommendations and monitors compliance.

No. 28   to Veterans Health Administration (VHA)

The deputy director ensures that full and empty oxygen gas cylinders are physically separated and clearly labeled and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00057-238 | Summary | Report

Recommendations (14)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 facility director requires the patient safety manager to ensure completion of the required minimum of eight root cause analyses each fiscal year and monitors patient safety manager’s compliance.

No. 3   to Veterans Health Administration (VHA)

The facility director makes certain that the patient safety manager or designee includes all the required elements in root cause analyses and monitors patient safety manager’s compliance.

No. 4   to Veterans Health Administration (VHA)

The facility director ensures that managers consistently implement improvement actions arising from root cause analysis activities and evaluate actions taken for sustained improvement and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The facility director ensures the patient safety manager or designee provides feedback to individuals or departments who submit patient safety incidents that result in root cause analysis and monitors patient safety manager compliance.

No. 6   to Veterans Health Administration (VHA)

The chief of staff ensures ongoing professional practice evaluations utilize assessments by providers with similar training and privileges and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The associate director ensures that a safe and clean environment is maintained throughout the facility and Selma VA Clinic and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The associate director ensures the VA police respond to panic alarm testing in the locked mental health unit and document response time and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The associate director ensures that the comprehensive emergency management plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

The facility director makes certain that primary care and mental health 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 ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.

No. 12   to Veterans Health Administration (VHA)

The director makes certain that the chief of staff assigns a women’s health medical director or clinical champion and monitors chief of staff’s compliance.

No. 13   to Veterans Health Administration (VHA)

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

No. 14   to Veterans Health Administration (VHA)

The chief of staff ensures that providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-07818-242 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Louis Stokes Cleveland VA Medical Center Director defines what elements are required for a medical screening exam to deem a patient medically stable prior to transfer to the Psychiatric Assessment and Observation Center.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01879-232 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Caribbean Healthcare System Director strengthens procedures to ensure that medical oncology staff monitor patients receiving chemotherapy to assess for toxicity symptoms and patient tolerance, and the monitoring is documented in the electronic health record.

No. 2   to Veterans Health Administration (VHA)

The VA Caribbean Healthcare System Director ensures that program managers assess the need for care coordination agreements between the community living center and specialty services and, if warranted, implement the agreement(s).

No. 3   to Veterans Health Administration (VHA)

The VA Caribbean Healthcare System Director partners with community living center managers to provide education to nursing staff on the communication of patient status changes using the observation and communication tool, and procedures as outlined in VA Caribbean Healthcare System policy.

No. 4   to Veterans Health Administration (VHA)

The VA Caribbean Healthcare System Director makes certain that community living center managers conduct a review of patient care plans to confirm their accuracy, update them as necessary, and strengthen processes to prevent future omissions as warranted.

No. 5   to Veterans Health Administration (VHA)

The VA Caribbean Healthcare System Director verifies that primary care physicians receive the education on the management of patients with prostate cancer being provided to urology and radiation oncology physicians.

No. 6   to Veterans Health Administration (VHA)

The VA Caribbean Healthcare System Director ensures that the findings identified by Veterans Integrated Service Network reviewers as noted in this report are addressed and resolved.

No. 7   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 8 Director makes certain that consistent and clear instructions are provided for all management reviews conducted concurrently by independent reviewers.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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