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

OIG Reports

| 17-04127-266 | Summary | Report | Redacted

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Sierra Pacific Network Director confers with the Offices of General Counsel,Human Resources, and Accountability and Whistleblower Protection to determine theappropriate administrative action to take, if any, against Dr. Erckenbrack.

No. 2   to Veterans Health Administration (VHA)

The VA Sierra Pacific Network Director confers with the Offices of General Counsel,Human Resources, and Accountability and Whistleblower Protection to determine theappropriate administrative action to take, if any, against the Chief of LogisticsManagement Service.

No. 3   to Veterans Health Administration (VHA)

The VA Sierra Pacific Network Director confers with the Office of General Counsel andthe Director of the VA Northern California Health Care System to ensure that controlsare in place to oversee proper implementation by the Health Care System of federal law,regulations, and VA policy regarding the use of government-owned vehicles.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-04593-10 | Summary | Report

Recommendations (12)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director ensures that Sterile Processing Services staff adhere to the missing instrument procedures for sterile sets as required by Veterans Health Administration policy.

No. 2   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director ensures that Sterile Processing Services staff adhere to the requirements for verification of items in sterile sets as required by Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director evaluates patient safety reporting systems to ensure that all events are captured in WebSPOT as required by Veterans Health Administration policy.

No. 4   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director ensures that all Sterile Processing Services staff, including contract staff, complete training as required by Veterans Health Administration Directive 1116 (2).

No. 5   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director verifies that Sterile Processing Services managers maintain an accurate list for reusable medical equipment and copies of manufacturers’ instructions as required by Veterans Health Administration policy and the April 2017 Deputy Under Secretary for Health for Operations and Management memorandum.

No. 6   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director ensures that Sterile Processing Services maintain updated and readily accessible standard operating procedures for all instruments and equipment within Sterile Processing Services in accordance with Veterans Health Administration policy.

No. 7   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director ensures that competency assessments for all Sterile Processing Services staff, including contract staff, are conducted and documented as required by Veterans Health Administration Directive 1116 (2).

No. 8   to Veterans Health Administration (VHA)

The New Mexico VA Health Care System Director reviews the contract related to Sterile Processing Services technicians to determine if requirements for training and certification are consistent with Veterans Health Administration Directive 1116 (2) and takes action as necessary.

No. 9   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 22 Director ensures that the New Mexico VA Health Care System Director implements action items from previous external Sterile Processing Services inspection reviews.

No. 10   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 22 Director oversees implementation of this report’s recommendations that are directed to the New Mexico VA Health Care System Director.

No. 11   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 22 Director reviews the New Mexico VA Health Care System’s Sterile Processing Services risk assessment to determine if identified high-risk items and areas are in alignment with guidance from the Deputy Under Secretary for Health for Operations and Management and takes action as necessary.

No. 12   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 22 implements a process that identifies instances when independent verification by Veterans Integrated Service Network staff is necessary to ensure that the Facility implements action plans related to Sterile Processing Services recommendations.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01496-301 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive in Charge, Veterans Health Administration, should develop requirements for medical facilities with emergency caches to perform at least annually a wall-to-wall inventory of all cache drugs and supplies, and develop processes to (1) label all expired or excess drugs that are purposefully maintained to respond to drug shortages or for the purposes of Shelf Life Extension testing, and (2) remove and rectify cases of other expired, missing, or excess drugs.

No. 2   to Veterans Health Administration (VHA)

The Executive in Charge, Veterans Health Administration, should conduct an assessment to determine if the cost saving benefits of the Shelf Life Extension Program outweigh the risks expired drugs pose to the emergency cache’s mission and to take corrective action as appropriate.

No. 3   to Veterans Health Administration (VHA)

The Executive in Charge, Veterans Health Administration, should improve emergency cache inventory management processes to ensure emergency cache national inventory data sorted by location is reliable and accurately identifies the expiration dates of all cache contents, including Shelf Life Extension Program drugs, and that this information is electronically accessible to each facility.

No. 4   to Veterans Health Administration (VHA)

The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program with a requirement for inventory to be timely rotated into the emergency cache after it is received.

No. 5   to Veterans Health Administration (VHA)

The Executive in Charge, Veterans Health Administration, should assess whether the Emergency Cache Program is properly aligned within VA and coordinate with other VA offices as necessary to determine the appropriate roles and responsibilities by program office, and then review, update, and reissue Emergency Cache Program requirements to include (1) robust annual cache inspection and activation exercise requirements, (2) processes to ensure cache inspection and activation requirements are met, (3) processes to ensure that violations identified during annual cache inspections are timely addressed, and (4) specific accountability measures for the program offices and local facility personnel responsible for program oversight.

No. 6   to Veterans Health Administration (VHA)

The Executive in Charge, Veterans Health Administration, should conduct a comprehensive assessment of the cache inventory to identify drugs and supplies that can be readily used in medical facilities’ general operations and develop a mechanism to monitor and ensure medical facilities are maximizing the use of these items before they expire.

No. 7   to Veterans Health Administration (VHA)

The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program to reflect the Office of Public Health’s reorganization and reassign responsibilities as needed.

Total Monetary Impact of All Recommendations

Open: $ 34,263,584.00
Closed: $ 0.00

| 18-01136-313 | Summary | Report

Recommendations (9)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 Facility Director ensures the interdisciplinary group or committee that reviews utilization management data includes required representatives and meets regularly and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Medical Executive Council uses and documents the use of the results of Ongoing Professional Practice Evaluations in the determination of whether to recommend continuation of licensed independent practitioners’ privileges and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures that damaged furniture is repaired or removed from service and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures weekly inspections of the emergency power supply system are performed and documented and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

7. The Facility Director ensures that controlled substance inspectors perform reconciliation of controlled substance dispensing from the pharmacy to automated dispensing cabinets and returns to pharmacy stock during monthly area inspections and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

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

No. 9   to Veterans Health Administration (VHA)

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

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-05570-06 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Service Chiefs initiate and complete Focused Professional Practice Evaluations for newly hired licensed independent providers and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Ongoing Professional Practice Evaluations include the review of service-specific practitioner data and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Ongoing Professional Practice Evaluations of pathology practitioners include required pathology-specific criteria, as appropriate, and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Deputy Director ensures that clean and dirty equipment is stored separately and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Deputy Director ensures that bottom shelves in equipment storage areas are solid and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

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

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01140-312 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from the Chief Business Office Revenue–Utilization Review and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Facility Director ensures that 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 Director ensures that managers consistently implement improvement actions arising from peer review and root cause analysis activities and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

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

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff ensures that clinical managers initiate and complete Focused and Ongoing Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

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

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures that mammogram results are communicated to ordering providers and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff ensures providers or designees communicate mammogram results to patients and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-05535-292 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits ensures cases requiring final competency determinations are entered into the Beneficiary Fiduciary Field System as soon as the cases are established in the Veterans Benefits Management System.

No. 2   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits reminds Veterans Benefits Administration staff of their responsibility to notify Fiduciary Hubs when waivers are received of the due process notification period for cases with proposed incompetency, and implements a plan to ensure compliance.

No. 3   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits implements a plan to ensure the processing of final competency determinations under the jurisdiction of the Fiduciary Hubs meet Veterans Benefits Administration’s established timeliness standard.

No. 4   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits implements a plan to prioritize the processing of final competency determinations under the jurisdiction of Veterans Service Centers and Pension Management Centers.

No. 5   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits ensures the National Work Queue distributes final competency determinations according to the Veterans Benefits Administration policy for processing these cases.

No. 6   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits implements a plan to ensure Fiduciary Hub staff who complete final competency determinations have access to documents containing federal taxpayer information in the Legacy Content Manager.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-00474-300 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA); Office of Acquisitions, Logistics, and Construction (OALC)

The Principal Executive Director, Office of Acquisition, Logistics, and Construction and the Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System implement a plan that puts the West LA campus in compliance with the West Los Angeles Leasing Act of 2016, the Draft Master Plan, and other federal laws, including reasonable time periods to correct deficiencies noted in this report.

No. 2   to Veterans Health Administration (VHA); Office of Acquisitions, Logistics, and Construction (OALC)

The Principal Executive Director, Office of Acquisition, Logistics, and Construction and the Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System ensure all non-VA entities operating on the West LA campus with expired or undocumented land use agreements establish new agreements compliant with the West Los Angeles Leasing Act.

No. 3   to Veterans Health Administration (VHA)

The Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System create a process to allow the Veterans Community Oversight and Engagement Board an opportunity to provide input to the executive leadership on West LA campus land use.

No. 4   to Office of Acquisitions, Logistics, and Construction (OALC)

The Principal Executive Director, Office of Acquisition, Logistics, and Construction create documented policies and procedures for out leases and Revocable Licenses to govern their use, management, and pricing to ensure fair value is received and negotiations are documented.

No. 5   to Veterans Health Administration (VHA)

The Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System ensure VA’s Capital Asset Inventory accurately reflects all land use agreements six months or longer on West LA campus.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-04875-308 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Integrated System Network 10 Director ensures the VA Ann Arbor Healthcare System Director complies with Veterans Health Administration policies regarding requirements for root cause analysis, peer review, and institutional disclosure.

No. 2   to Veterans Health Administration (VHA)

The VA Ann Arbor Healthcare Facility Director applies quality management processes to evaluate modifications made by the anesthesiologist and surgeon for cardiothoracic surgeries and determines if modifications should be implemented system-wide.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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