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

OIG Reports

| 18-02056-54 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.

No. 2   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of electrocardiogram test results and follow-up as clinically indicated.

No. 3   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.

No. 4   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of medication blood level test results and follow-up as clinically indicated.

No. 5   to Veterans Health Administration (VHA)

The VA Illiana Health Care System Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.

No. 6   to Veterans Health Administration (VHA)

The VA Illiana Health Care System Director strengthens processes for effective clinical consultation and follow-up between mental health and collaborating primary care providers.

No. 7   to Veterans Health Administration (VHA)

The VA Illiana Health Care System Director strengthens the processes for congressional inquiry response to ensure response timeliness, clinical information accuracy, and records retention, as required.

No. 8   to Veterans Health Administration (VHA)

The VA Illiana Health Care System Director evaluates staff actions and approval processes in the preparation of the letter to Senator Donnelly, and takes appropriate administrative action, if indicated.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01155-48 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs collect Ongoing Professional Practice Evaluation data utilizing assessments by providers with similar training and privileges and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director ensures Police Service regularly tests panic alarm testing and addresses identified deficiencies at the Harrisburg Community Based Outpatient Clinic and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures that the Emergency Operations Plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures controlled substances inspectors verify a corresponding sealed evidence bag containing drug(s) for each medication held for destruction at the Evansville Health Care Center and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01164-42 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that clinical managers initiate and document Focused Professional Practice Evaluations that include provider- and service-specific criteria for the determination of providers’ privileges and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Ongoing Professional Practice Evaluations include service-specific criteria and are completed by a provider with similar training and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures that the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluations in the consideration to grant provider privileges and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director–Lyons Campus ensures that managers store clean and dirty medical equipment separately and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director–Lyons Campus ensures that Public Safety Service documents the response times when testing panic alarms and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01147-47 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Facility Director ensures that Controlled Substances Inspection program staff have no access to or involvement in drug procurement, prescribing, or dispensing, or administration of controlled substances and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Facility Director ensures that Controlled Substances Inspectors perform reconciliation of controlled substance returns to pharmacy stock from every automated dispensing cabinet and monitors compliance.

No. 4   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 compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01153-43 | Summary | Report

Recommendations (12)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 compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures an interdisciplinary Facility group reviews utilization management data and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs present the results of completed Focused Professional Practice Evaluations to the Medical Executive Committee to recommend continuing the initially granted privileges and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures that Facility managers maintain a clean and safe environment throughout the Facility and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures that all staff properly safeguard patient health information and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Associate Director ensures the VA Police document response times to panic alarm testing in the locked mental health unit and monitors compliance.

No. 8   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. 9   to Veterans Health Administration (VHA)

The Facility Director ensures that all deficiencies identified on the Annual Physical Security Surveys are addressed and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

The Facility Director ensures that controlled substances inspectors verify written or electronic controlled substance orders during monthly area inspections and monitors compliance.

No. 11   to Veterans Health Administration (VHA)

The Facility Director ensures that controlled substance inspectors complete routine monthly controlled substance inspections and monitors compliance.

No. 12   to Veterans Health Administration (VHA)

The Facility Director ensures that geriatric evaluation program performance improvement activities are conducted and reviewed by an appropriate leadership board and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-00693-41 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Cheyenne VA Medical Center Director ensures timely surveillance for cancer patients.

No. 2   to Veterans Health Administration (VHA)

The Cheyenne VA Medical Center Director improves processes for care coordination and communication between Cheyenne VA Medical Center providers and non-VA providers for cancer patients.

No. 3   to Veterans Health Administration (VHA)

The Cheyenne VA Medical Center Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.

No. 4   to Veterans Health Administration (VHA)

The Cheyenne VA Medical Center Director confers with the Office of Chief Counsel in accordance with Veterans Health Administration Handbook 1004.08 regarding institutional disclosures and takes action as necessary.

No. 5   to Veterans Health Administration (VHA)

The Cheyenne VA Medical Center Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.

No. 6   to Veterans Health Administration (VHA)

The Iowa City VA Health Care System Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.

No. 7   to Veterans Health Administration (VHA)

The Iowa City VA Health Care System Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01146-35 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Executive Council of Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion to recommend approval of clinical privileges for LIPs and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Facility Director ensures Controlled Substances Inspectors complete monthly pharmacy prescription pad inventories and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01163-36 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Facility Director ensures all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Facility Director ensures the Patient Safety Manager or designee provides feedback to employees or departments who submit patient safety incidents that result in root cause analysis and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures Focused and Ongoing Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and Fort Knox Community Based Outpatient Clinic and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures staff assigned to conduct mental health environment of care inspections use the Mental Health Environment of Care Checklist to identify and correct deficiencies in a timely manner and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures the Facility’s Emergency Operations Plan includes required elements and that the annual review of inventory and assets is conducted and documented and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The Facility Director ensures that all deficiencies identified on the annual physical security survey are addressed and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01278-13 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The OIG recommended the Under Secretary for Benefits direct Compensation Service and Office of Field Operations to develop and implement processes and procedures that ensure monitoring of Survivors’ and Dependents’ Educational Assistance electronic mailboxes and timely establishment of compensation adjustments.

No. 2   to Veterans Benefits Administration (VBA)

The OIG recommended the Under Secretary for Benefits direct Education Service to develop and implement an effective process to ensure receipt of Survivors’ and Dependents’ Educational Assistance benefit notifications by VA Regional Office staff.

No. 3   to Veterans Benefits Administration (VBA)

The OIG recommended the Under Secretary for Benefits ensure Compensation Service and Education Service develop electronic system functionality to identify cases with potential duplication of benefits when a dependent begins receiving Survivors’ and Dependents’ Educational Assistance payments.

No. 4   to Veterans Benefits Administration (VBA)

The OIG recommended the Under Secretary for Benefits ensure the National Work Queue and Compensation Service assign cases with compensation adjustments to remove the school child allowance as soon as the cases are ready for processing.

No. 5   to Veterans Benefits Administration (VBA)

The OIG recommended the Under Secretary for Benefits ensure Office of Field Operations takes prompt action to adjust benefits for cases in the OIG sample in which payment duplications had not been identified.

Total Monetary Impact of All Recommendations

Open: $ 22,500,000.00
Closed: $ 0.00

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