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

OIG Reports

| 19-06864-183 | Summary | Report

Recommendations (14)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.

No. 3   to Veterans Health Administration (VHA)

The Medical Center Director determines reasons for noncompliance and ensures that root cause analyses include all required review elements.

No. 4   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. 5   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete provider exit review forms within seven calendar days of licensed health care professionals’ departure from the medical center.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavior risk assessment on all patients prior to initiating long-term opioid therapy.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients when initiating long-term opioid therapy.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff determines reasons for noncompliance and ensures healthcare providers follow up with patients within the required timeframe after initiating long-term opioid therapy.

No. 10   to Veterans Health Administration (VHA)

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

No. 11   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that practitioners complete and document all required elements of life-sustaining treatment plan progress notes.

No. 12   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and certifies that a multidisciplinary committee is established to review proposed life-sustaining treatment plans.

No. 13   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Advisory Committee For Women Veterans includes required core members.

No. 14   to Veterans Health Administration (VHA)

The Associate Director for Patient Service evaluates and determines any additional reasons for noncompliance and makes certain that Chief of Sterile Processing Services completes valid competency assessments for staff reprocessing reusable medical equipment.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-09416-186 | Summary | Report

Recommendations (17)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define and document expectations for focused professional practice evaluations in provider profiles prior to assessment.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that first- or second-line supervisors complete provider exit review forms within seven calendar days of a provider’s 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 providers complete a behavior risk assessment that includes a history of substance abuse, psychological factors, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for concurrent opioid and benzodiazepine medication therapy.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff determines the reason for noncompliance and make certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff determines the reasons for noncompliance and makes certain that healthcare providers obtain and document informed consent consistently for patients prior to initiating long-term opioid therapy.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within the required time frame after initiating long-term opioid therapy.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up of patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.

No. 10   to Veterans Health Administration (VHA)

The Interim Medical Center Director determines the reasons for noncompliance and ensures that the Pain Management Sub-Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.

No. 11   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians conduct four follow-up appointments, either face-to-face or telephonic with documented consent, within the required time frame.

No. 12   to Veterans Health Administration (VHA)

The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain staff receive annual suicide prevention refresher training.

No. 13   to Veterans Health Administration (VHA)

The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when CBOCs have only one designated provider.

No. 14   to Veterans Health Administration (VHA)

The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee is comprised of the required core members.

No. 15   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.

No. 16   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.

No. 17   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00230-190 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Acquisitions, Logistics, and Construction (OALC)

The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction requires in any award made on a noncompetitive basis that the contracting officer obtain a written disclosure and certification by the program sponsor, contracting officer’s representative, and other staff involved in the procurement as appropriate, disclosing any personal or professional relationship between such staff and vendor personnel.

No. 2   to Office of Acquisitions, Logistics, and Construction (OALC)

The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the conduct and performance of the contracting officer, the Agency Competition Advocate, and the two higher-level supervisors involved in this procurement.

No. 3   to Office of Acquisitions, Logistics, and Construction (OALC); Office of Operations, Security & Preparedness

The Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness determines what administrative action should be taken, if any, with respect to the conduct and performance of the HR&A Program Director and the Contracting Officer’s Representative.

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

VA’s Senior Procurement Executive determines what action, if any, should be taken with respect to the contracting officer’s warrant consistent with the authority granted by VA Acquisition Regulation § 801.690-6.

No. 5   to Office of General Counsel (OGC)

The Acting General Counsel reviews the circumstances of this procurement and uses that information to help determine whether it is appropriate for counsel to sign attestations on Justification and Approval forms, and issues policy guidance in accordance with that determination.

No. 6   to Office of Acquisitions, Logistics, and Construction (OALC)

The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction, in consultation with the Office of General Counsel, reviews the Small Business contract to determine what actions should be taken, if any, to recover funds or otherwise address the waste of VA funds.

No. 7   to Office of Acquisitions, Logistics, and Construction (OALC)

The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the contracting officers’ acceptance of substitute performance that provided no value to VA.

No. 8   to Office of Human Resources and Administration; Office of Operations, Security & Preparedness

The Assistant Secretary of Human Resources and Administration (HR&A) / Operations, Security, and Preparedness determines what administrative action to take, if any, with respect to the Contracting Officer Representative’s failure to perform diligence sufficient to identify the cloud-computing issues associated with this procurement.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-00017-191 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health completes a specialty care needs assessment for highly rural community-based outpatient clinics to include internet bandwidth and telehealth equipment and develops options for the delivery of safe patient care.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that the Veterans Health Administration Site Tracking system validation process is completed by each Veterans Integrated Service Network as required and monitors for compliance.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that facilities and Veterans Integrated Service Networks maintain accurate and current information on websites as required and monitors for compliance.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health completes an assessment to determine whether highly rural community-based outpatient clinics that are located in a non-VA community hospital or health care center are fully utilizing the resources available at the non-VA facilities and takes action as indicated.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-00082-189 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff determines the reasons for noncompliance and ensures all staff complete annual suicide prevention refresher training.

No. 2   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.

No. 3   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are included in the Women Veterans Health Committee charter and attend the quarterly meetings.

No. 4   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-07543-178 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director conducts a comprehensive review of the patient’s care including collaboration among Patient Aligned Care Team members and takes action as indicated.

No. 2   to Veterans Health Administration (VHA)

The Tennessee Valley Healthcare System Director ensures facility staff are aware of and follow Veterans Health Administration Directive 1088, Communicating Test Results to Providers and Patients, specifically the requirement for the ordering clinician to communicate all test results to patients.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-09377-192 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health initiates review of the Veterans Health Administration’s credentialing policy to determine the need for requirement clarification related to prior employment history to include applicant listing of locum tenens contracting companies.

No. 2   to Veterans Health Administration (VHA)

The W. G. (Bill) Hefner VA Medical Center Director ensures credentialing and privileging staff verify applicants’ information within the required timeframe outlined by Veterans Health Administration policy and monitors for compliance.

No. 3   to Veterans Health Administration (VHA)

The W. G. (Bill) Hefner VA Medical Center Director ensures annual proficiency reports are completed and maintained consistent with Veterans Health Administration requirements and monitors for compliance.

No. 4   to Veterans Health Administration (VHA)

The W. G. (Bill) Hefner VA Medical Center Director ensures all available performance and competency information is provided to the Professional Standards Board for consideration during provider probationary and reprivileging reviews and monitors for compliance.

No. 5   to Veterans Health Administration (VHA)

The W. G. (Bill) Hefner VA Medical Center Director ensures that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-09436-185 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director considers developing a facility policy for bariatric surgery to include preoperative medical and mental health evaluations.

No. 2   to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director ensures that bariatric patients receive all preoperative medical and mental health evaluations and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director reviews the documentation error noted in this report and takes action as appropriate.

No. 4   to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director provides education to staff on how to correct documentation errors and the requirement to follow facility policy.

No. 5   to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director ensures interdisciplinary discussions about preoperative bariatric patients are documented in the electronic health record and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The VA Pittsburgh Healthcare System Director considers a programmatic review of the Bariatric Surgery Program to ensure patients receive a comprehensive preoperative evaluation and postoperative follow-up care.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-00067-172 | Summary | Report

Recommendations (11)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff determines the reason(s) for noncompliance and ensures that ongoing professional practice evaluations include service-specific criteria.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Executive Committee minutes consistently reflect the review of professional practice evaluation results.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing for patients prior to initiating or continuing long-term opioid therapy and periodically thereafter.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within the required time frame after initiating long-term opioid therapy.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.

No. 9   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the VISN Sterile Processing Services Management Board.

No. 10   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that include at least two methods of verification for reprocessing reusable medical equipment.

No. 11   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-07281-105 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health conduct a formal analysis of VHA’s Office of Community Care prescription drug programs to determine what steps VA would need to take to require drug manufacturers to provide Big 4 prices for covered prescription drugs purchased for CHAMPVA and any other VA Community Care programs that use a retail pharmacy.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health collaborate with the Office of Regulatory and Administrative Affairs and, if determined appropriate, pursue any proposed statutory or other changes needed to provide VA with the appropriate legal authority to purchase all prescription drugs through retail pharmacies at the Big 4 prices.

Total Monetary Impact of All Recommendations

Open: $ 345,100,000.00
Closed: $ 0.00

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