OIG Reports

No. 1   to Veterans Health Administration (VHA)

The deputy undersecretary for health for the Office of Community Care, with the assistance of the Office of General Counsel as appropriate, ensures that the Office of Community Care’s Equal Employment Opportunity Office and its Revenue Operations group are correctly interpreting and complying with VA Handbook 5975.5 and VA’s Financial Policies and Procedures with regard to the administration of Special Emphasis Programs, including the purchase of food.

No. 2   to Veterans Health Administration (VHA)

The principal executive director and chief acquisition officer of the Office of Acquisition, Logistics and Construction and the deputy undersecretary for health for the Office of Community Care ensure that their staff are appropriately trained on requirements for compliance with VA Directive 6371 governing the destruction of temporary paper records.

No. 1   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health update the high cost, high tech medical equipment application to provide clearer instructions on preparing requests and providing supporting documentation for robotic surgical systems. The application and instructions should be disseminated to medical facilities, Veterans Integrated Service Networks, and responsible central office organizations.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health establish controls to ensure information in high cost, high tech medical equipment applications is reviewed and validated before recommending final approval to the assistant deputy under secretary for health for administrative operations.

No. 3   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health evaluate the need and justification of the 10 robotic surgical systems at VA medical facilities that were acquired without approval by the assistant deputy under secretary for health for administrative operations.

No. 4   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health develop guidance for accurately and consistently coding robotic surgical procedures in the Veterans Health Information Systems and Technology Architecture.

No. 5   to Veterans Health Administration (VHA)

The OIG recommended the under secretary for health evaluate the need for the National Surgery Office to obtain robotic surgical procedure data from the system manufacturer to assess and validate the use of the systems at VA medical facilities.

No. 1   to Veterans Health Administration (VHA)

The Boise VAMC director confers with the Office of General Counsel to determine whether administrative action should be taken against the nonprofit’s current executive director concerning: (a) the processing of salary increases for the former executive director and herself without written authorization and performance evaluations as required by IVREF policies and (b) the failure to report the former executive director’s conduct regarding the salary increase to the board of directors.

No. 2   to Veterans Health Administration (VHA)

The Boise VAMC director makes certain the Idaho Veterans Research and Education Foundation board of directors implements controls requiring two or more responsible officials to provide oversight of all salary and pay rate changes.

No. 3   to Veterans Health Administration (VHA)

The Boise VAMC director ensures the Idaho Veterans Research and Education Foundation board of directors implements controls for the use of credit cards and the receipt, review, and reconciliation of credit card statements.

No. 4   to Veterans Health Administration (VHA)

The Boise VAMC director establishes procedures that require the Research and Development Budget Office staff to review VA-affiliated nonprofit corporation invoices to confirm services were performed or goods were received in accordance with Intergovernmental Personnel Act agreements before approving invoices for payment.

No. 5   to Veterans Health Administration (VHA)

The Boise VAMC director institutes procedures to make certain the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.

No. 1   to Veterans Health Administration (VHA)

The Hunter Holmes McGuire VA Medical Center Director ensures prescriber education on prior authorization drug request consultation procedures including consult documentation options, urgency level communication, patient notification, and appeals processes.

No. 2   to Veterans Health Administration (VHA)

The Hunter Holmes McGuire VA Medical Center Director promotes mental health prescribers’ utilization of the prior authorization drug request process in consideration of the medication plan most effective for each patient.

No. 3   to Veterans Health Administration (VHA)

The Hunter Holmes McGuire VA Medical Center Director ensures that electronic health records are reviewed for improper entries, and takes action as indicated.

No. 4   to Veterans Health Administration (VHA)

The Hunter Holmes McGuire VA Medical Center Director conducts a review of staff improper electronic health record entries and electronic mail and consults with Office of Human Resources to determine if administrative action is warranted, and takes action as appropriate.

No. 5   to Veterans Health Administration (VHA)

The Hunter Holmes McGuire VA Medical Center Director evaluates ways to improve the workplace relationships between Mental Health and Pharmacy Services staff, including consultation with the Veterans Integrated Services Network or the National Center for Organizational Development, and takes actions as appropriate.

No. 1   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director ensures that Emergency Department physicians receive training on the facility’s acute coronary syndrome protocol and verifies that ST-elevation myocardial infarction time goals are monitored, and improvements implemented as needed.

No. 2   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director makes certain a facility policy that is applicable to all patient care areas outlines standardized processes for safe and timely interfacility transfers, including communication of appropriate transport services needed.

No. 3   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director conducts an analysis of the contributing factors that led to the delay in the patient’s interfacility transfer and takes action as necessary to improve identified deficiencies.

No. 4   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director ensures the newly implemented Emergency Department Interfacility Transfers policy is reviewed and updated to include improvements as data are obtained from the interfacility transfer analysis.

No. 5   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director makes certain that Emergency Department and Health Administrative Service staff are trained on the Emergency Department Interfacility Transfers policy, the updated service agreement between Cardiology and Emergency Departments, and interfacility transfer process and monitors the transfer process, including timeliness of transfers.

No. 6   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director ensures the Critical Care Committee evaluates all concerns identified during code events, makes recommendations for improvement, confirms actions are implemented, and assesses effectiveness of actions.

No. 7   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director ensures the Chief, Quality Management is a member of the Critical Care Committee, develops a process to address problems in obtaining the assistance of Emergency Medical Services or use of the 911 call system, and assesses the effectiveness of the process.

No. 8   to Veterans Health Administration (VHA)

The VA Heartland Network Director reviews the peer reviews of physicians who provided care to the patient to determine if a focused clinical review by an independent reviewer is warranted and takes actions as necessary.

No. 9   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director reviews the patient’s care provided in the Emergency Department and the circumstances of the interfacility transfer to determine if an institutional disclosure is warranted.

No. 10   to Veterans Health Administration (VHA)

The Robert J. Dole VA Medical Center Director ensures interfacility transfer data are collected, analyzed, and incorporated into the Robert J. Dole VA Medical Center’s quality management program as required by Veterans Health Administration policy.

No. 1   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health consider developing an oversight mechanism that includes the VISN Surgery Integrated Clinical Community Chair in the monitoring of medical facility operating room efficiency and surgical support element problems and ensures VISN Directors hold medical facilities accountable when these problems persist and reduce operating room efficiency.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health consider periodically analyzing two to three years of operating room efficiency data to identify medical facilities that have not consistently met National Surgery Office efficiency goals and assess surgical support element problems impacting patients and operating room efficiency.

No. 3   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office clarify the intent of the current utilization measure and assess other utilization measures other than staffing.

No. 4   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health consider requiring the National Surgery Office gather as part of its capacity measure information about operating room closures or reduced usage, including the reasons for the closures or curtailment of surgeries.

No. 5   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health consider identifying surgical support element best practices used by efficient facilities and ensure less efficient medical facilities, where appropriate, implement these practices to address problems, reduce surgical cancellations and delays, and minimize patient risks.

No. 6   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health consider requiring medical facility surgical work groups to discuss the National Surgery Office Efficiency goals and their facility’s performance with support services, such as logistics, sterile processing service, and environment management service, at least quarterly and ensure they all work proactively and collaboratively to address surgical support element problems.

No. 1   to Veterans Benefits Administration (VBA)

Determine what additional actions are needed to make certain that staff understand how to accurately apply the most current guidance to the date of receipt recorded for claims received during the national state of emergency and implement those actions.

No. 2   to Veterans Benefits Administration (VBA)

Conduct a review to ensure claims received and completed from March 1, 2020, had the correct date of entitlement applied.

No. 3   to Veterans Benefits Administration (VBA)

Reevaluate guidance for the date of receipt recorded for claims without a postmark received during the national state of emergency.

No. 1   to Veterans Health Administration (VHA)

The Network Director evaluates and determines the reasons for noncompliance and ensures that the Sterile Processing Services Management Board conducts Veterans Integrated Service Network-led facility reusable medical equipment inspections.

No. 2   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are provided to executive leaders.

No. 3   to Veterans Health Administration (VHA)

The Network Director determines the reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are posted within the required time frame.

No. 4   to Veterans Health Administration (VHA)

The Network Director determines the reasons for noncompliance and ensures that Veterans Integrated Service Network-led reusable medical equipment facility inspection corrective action plans are developed and tracked until closure.

No. 1   to Veterans Benefits Administration (VBA)

The under secretary for benefits ensures the adjudication procedures manual is updated for consistency with all applicable laws, regulations, and policies related to permanent and total determinations in consultation with the office of general counsel.

No. 2   to Veterans Benefits Administration (VBA)

The under secretary for benefits ensures decision-making staff support their permanent and total status decisions in the Reasons for Decision section of the rating decision by describing the evidence used to support their conclusions.

No. 3   to Veterans Benefits Administration (VBA)

The under secretary for benefits replaces the title and standardized language of “Dependents’ Educational Assistance under 38 U.S.C. Chapter 35” in rating decisions to clearly state that permanent and total status is being considered.

No. 4   to Veterans Benefits Administration (VBA)

The under secretary for benefits ensures appropriate training is provided to decision-making staff based on the changes made to permanent and total procedures related to Recommendations 1, 2 and 3, and monitor the effectiveness of that training.