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

OIG Reports

| 20-03593-140 | Summary | Report

Recommendations (15)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures actions are taken to clarify and broadly disseminate adjudicator expectations for follow-up of an unreturned INV Form 41.

No. 2   to Veterans Health Administration (VHA)

The Louis A. Johnson Medical Center Director ensures Pharmacy Service utilizes the required Veterans Health Information Systems and Technology Architecture Automatic Replenishment System to record medication usage data and maintain the records for inventory accountability.

No. 3   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 5 Director conducts management reviews of the care of patients 1–10 as discussed in this report and takes action as indicated.

No. 4   to Veterans Health Administration (VHA)

The Louis A. Johnson VA Medical Center Director reviews the availability and timeliness of endocrinology consults, and takes any corrective action needed.

No. 5   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 5 Director ensures evaluation of quality of care concerns or other irregularities (beyond hypoglycemia) of: cases provided by the OIG; cases that may otherwise be pertinent or concerning; and cases brought forward by patients and/or family members who express concerns or make other inquiries about care they received from Ms. Mays. As determined by the VISN, clinical experts external to the facility should be utilized when appropriate.

No. 6   to Veterans Health Administration (VHA)

The Louis A. Johnson Medical Center Director develops and disseminates guidance on clinical communication(s) to ensure that patient care and outcomes are routinely discussed in appropriate forums, such as interdisciplinary team meetings, and the discussions are documented.

No. 7   to Veterans Health Administration (VHA)

The Louis A. Johnson Medical Center Director ensures that close observation documentation is readily available in the electronic health record, and monitors for compliance.

No. 8   to Veterans Health Administration (VHA)

The Louis A. Johnson Medical Center Director ensures clinical documentation reviews are completed timely for patient safety and continuity of care.

No. 9   to Veterans Health Administration (VHA)

The Louis A. Johnson VA Medical Center Director evaluates the factors and processes surrounding employees’ failures to report and follow up on the unexplained hypoglycemic events, and takes action to ensure appropriate reporting of actual or potential patient safety events, system vulnerabilities, or other unexpected events that offer opportunities for lessons learned.

No. 10   to Veterans Health Administration (VHA)

The Louis A. Johnson Medical Center Director requires that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.

No. 11   to Veterans Health Administration (VHA)

The Louis A. Johnson Medical Center Director ensures that the interdisciplinary mortality review workgroup meet as required with appropriate reporting through oversight council(s), and monitors for compliance.

No. 12   to Veterans Health Administration (VHA)

The Louis A. Johnson Medical Center Director ensures that oversight and reporting practices align with Louis A. Johnson Medical Center policy requirements.

No. 13   to Veterans Health Administration (VHA)

The Under Secretary for Health determines the potential advantage of a rescue medication flagging system as an additional tool to evaluate unexplained adverse patient events, including but not limited to mortalities, and takes action as indicated.

No. 14   to Veterans Health Administration (VHA)

The Louis A. Johnson VA Medical Center Director takes action to prioritize and continue efforts to promote a strong culture of safety, such as periodic facility-wide refresher patient safety training or additional patient safety stand downs when indicated, and monitors for effectiveness.

No. 15   to Veterans Health Administration (VHA)

The Under Secretary for Health reevaluates how the Veterans Health Administration collects, reviews, and analyzes mortality data from VA facilities, and takes action to address identified gaps and weaknesses, as indicated.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-01593-102 | Summary | Report

Recommendations (12)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director consults with the VA Office of Mental Health and Suicide Prevention to review the classification and commitment of patients to the long-stay mental health recovery unit in the facility’s community living center, and makes recommendations to ensure the provision of safe mental health care to patients at the Chillicothe VA Medical Center.

No. 2   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director conducts a comprehensive review of the patient’s calendar year 2019 mental health care, including psychiatric care and medication management, and makes recommendations to the facility, if indicated.

No. 3   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director establishes a review process to ensure that community living center assessments clearly align the service offerings of the community living center with the individual needs of patients.

No. 4   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures development of a process to address the care needs of patients who are determined inappropriate for community living center admission.

No. 5   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director establishes a review process to ensure that community living center care plans are consistent with applicable Veterans Health Administration policy and communicated to the community living center staff caring for patients.

No. 6   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures all community living center long-stay mental health recovery unit staff receive mental health training and pass competency evaluations to provide care specific to the needs of the population served.

No. 7   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures that all facility staff are trained on, and comply with, the facility policy concerning patient behavior management.

No. 8   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures that all facility community living center staff report near-miss and actual missing patient events to patient safety staff and monitors for compliance.

No. 9   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures that patient safety staff review reported events for patterns or trends indicating risks to patients with a need for mitigation and confirms that effective mitigation strategies are initiated.

No. 10   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures all facility community living center staff receive initial orientation on how to prevent and respond to missing patient events, activating all alerts and involving all relevant staff, as required.

No. 11   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director reviews the facility’s policy on missing patients, ensures that it clearly outlines actions staff should take to prevent missing patient events, and verifies that relevant staff are trained and knowledgeable about such actions.

No. 12   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures that VA police officers receive training and resources to provide missing patient alerts to all facility staff and appropriate law enforcement agencies.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-02265-100 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director develops an oversight plan to address concerns regarding the employee’s compliance with Sterile Processing Services’ procedures as identified by facility and Veterans Integrated Services Network leaders and the Clinical Episode Review Team and confirms effective resolution.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that the Clinical Episode Review Team reviews the OIG-provided biomedical equipment manufacturer’s information for the automated endoscope reprocessor to determine if the information alters their determination regarding the potential risk to patients or the need for a large-scale disclosure and takes action as necessary.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-01272-129 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Executive Quality Leadership Council recommends and takes action in response to identified problems or opportunities for improvement.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Medicine includes the minimum gastroenterology-specific criteria for ongoing professional practice evaluations of licensed independent gastroenterology practitioners.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.

No. 4   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that Provider Exit Review Forms are completed within seven business days of licensed healthcare practitioners’ departure from the medical center.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.

No. 6   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings

No. 7   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures align with the manufacturer’s instructions for use.

No. 8   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all current Sterile Processing Services employees complete Level 1 training and all new employees complete Level 1 training within 90 days of hire.

No. 9   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete competency assessments that align with standard operating procedures and manufacturers’ instructions for use.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-01927-104 | Summary | Report

Recommendations (26)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

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

We recommended the Assistant Secretary for Information and Technology consistently implement an improved continuous monitoring program in accordance with the NIST Risk Management Framework. Specifically, implement an independent security control assessment process to evaluate the effectiveness of security controls prior to granting authorization decisions.

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

We recommended the Assistant Secretary for Information and Technology implement improved mechanisms to ensure system stewards and information system security officers follow procedures for establishing, tracking, and updating Plans of Action and Milestones for all known risks and weaknesses including those identified during security control assessments.

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

We recommended the Assistant Secretary for Information and Technology implement controls to ensure that system stewards and responsible officials obtain appropriate documentation prior to closing Plans of Action and Milestones.

No. 4   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology develop mechanisms to ensure system security plans reflect current operational environments, include an accurate status of the implementation of system security controls, and all applicable security controls are properly evaluated.

No. 5   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology Implement improved processes for reviewing and updating key security documents such as security plans, risk assessments, and interconnection agreements on an annual basis and ensure the information accurately reflects the current environment.

No. 6   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure compliance with VA password policy and security standards on domain controls, operating systems, databases, applications, and network devices.

No. 7   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement periodic reviews to minimize access by system users with incompatible roles, permissions in excess of required functional responsibilities, and unauthorized accounts.

No. 8   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology enable system audit logs on all critical systems and platforms and conduct centralized reviews of security violations across the enterprise.

No. 9   to Office of Information and Technology (OIT)

We recommended the Office of Personnel Security strengthen processes to ensure appropriate levels of background investigations are completed for applicable VA employees and contractors and applicable investigation data is accurately tracked within the authoritative system of record.

No. 10   to Office of Information and Technology (OIT)

We recommended the Office of Personnel Security formalize the Position Descriptions and methodology used within the Human Resource business processes to ensure that employees with similar positions are required to have the same level of background investigation.

No. 11   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement more effective automated mechanisms to continuously identify and remediate security deficiencies on VA’s network infrastructure, database platforms, and web application servers.

No. 12   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement a more effective patch and vulnerability management program to address security deficiencies identified during our assessments of VA’s web applications, database platforms, network infrastructure, and workstations.

No. 13   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology maintain a complete and accurate security baseline configuration for all platforms and ensure all baselines are appropriately implemented for compliance with established VA security standards.

No. 14   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement improved network access controls that restrict medical devices from systems hosted on the general network.

No. 15   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology consolidate the security responsibilities for networks not managed by the Office of Information and Technology, under a common control for each site and ensure vulnerabilities are remediated in a timely manner.

No. 16   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement improved processes to ensure that all devices and platforms are evaluated using credentialed vulnerability assessments.

No. 17   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement improved procedures to enforce standardized system development and change control processes that integrates information security throughout the life cycle of each system.

No. 18   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology review system boundaries, recovery priorities, system components, and system interdependencies and implement appropriate mechanisms to ensure that established system recovery objectives are met.

No. 19   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology ensure contingency plans for all systems and applications are updated and tested in accordance with VA requirements.

No. 20   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement more effective agency-wide incident response procedures to ensure timely notification, reporting, updating, and resolution of computer security incidents in accordance with VA standards.

No. 21   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology ensure that VA’s Cybersecurity Operations Center has full access to all security incident data to facilitate an agency-wide awareness of information security events.

No. 22   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement improved safeguards to identify and prevent unauthorized vulnerability scans on VA networks.

No. 23   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement improved measures to ensure that all security controls are assessed in accordance with VA policy and that identified issues or weaknesses are adequately documented and tracked within POA&Ms.

No. 24   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology fully develop a comprehensive list of approved and unapproved software and implement continuous monitoring processes to prevent the use of prohibited software on agency devices.

No. 25   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology develop a comprehensive inventory process to identify connected hardware, software, and firmware used to support VA programs and operations.

No. 26   to Office of Information and Technology (OIT)

We recommended the Assistant Secretary for Information and Technology implement improved procedures for monitoring contractor-managed systems and services and ensure information security controls adequately protect VA sensitive systems and data.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-01266-117 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures action items are fully implemented when problems or opportunities for improvement are identified.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners with similar training and privileges complete ongoing professional practice evaluations.

No. 3   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that Provider Exit Review Forms are completed within seven business days of licensed independent practitioners’ departure from the medical center.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention coordinators complete suicide prevention safety plans within the required time frame and include contact information for professional agencies.

No. 5   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Women Veterans Health Committee meets regularly, appoints required members who consistently attend meetings, and reports to executive leaders.

No. 7   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures the Chief of Sterile Processing Services enforces the endoscopy clinic reprocessing area’s daily cleaning schedule.

No. 8   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity ranges are monitored and maintained in the Sterile Processing Services main supply room and endoscopy clinic reprocessing area.

No. 9   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all staff who reprocess reusable medical equipment receive monthly continuing education.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-00545-115 | Summary | Report

Recommendations (11)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of caller 1’s contacts, including the responder’s conduct, consults with Human Resources and General Counsel Offices, and takes action as warranted.

No. 2   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director ensures leaders’ awareness and understanding of administrative investigation board policy and procedures as applicable to the Veterans Crisis Line.

No. 3   to Veterans Health Administration (VHA)

The Montana VA Health Care System Director ensures that primary care providers include and document assessment and care plans for patients with mental health conditions.

No. 4   to Veterans Health Administration (VHA)

The Montana VA Health Care System Director makes certain that primary care providers comply with Veterans Health Administration policy regarding the electronic health record documentation of patients’ non-VA health records.

No. 5   to Veterans Health Administration (VHA)

The Executive Director, Office of Mental Health and Suicide Prevention, consults with relevant Veterans Health Administration program offices, including the National Center for Patient Safety, to establish applicable quality management processes and expectations including staff reporting of adverse events and close calls.

No. 6   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director evaluates Veterans Crisis Line leaders’ expectations regarding the percentage of silent monitored calls completed and establishes benchmarks for individual staff requirements.

No. 7   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director makes certain that root cause analyses are conducted as required by Veterans Health Administration policy.

No. 8   to Veterans Health Administration (VHA)

The Executive Director, Office of Mental Health and Suicide Prevention, determines if Veterans Health Administration disclosure policies apply to the Veterans Crisis Line and establishes procedures as appropriate.

No. 9   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director ensures processes are developed to promote responders’ communication regarding emergency dispatch for disconnected callers.

No. 10   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a full review of Veterans Crisis Line staff members’ contacts and rescue management with caller 2, consults with the Human Resources and General Counsel Offices, and takes action as warranted.

No. 11   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director strengthens supervisory oversight of social service assistants and clearly communicates expectations to all supervisory levels.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-01386-107 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health clarifies requirements for colonoscopy quality indicators for professional practice evaluation and ensures a process is in place to monitor compliance.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health strengthens requirements for colonoscopy quality assurance monitoring that includes analysis of quality indicators to identify trends and monitors for compliance.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with the National Gastroenterology Program Director, evaluates implementation of standardized endoscopy software across Veterans Health Administration facilities where colonoscopies are performed and takes action as indicated.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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