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

OIG Reports

| 17-03382-294 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures that the Mental Health Residential Rehabilitation Treatment Program nursing staff complete validated clinical scales to assess and quantify the severity of withdrawal symptoms for patients with opioid use disorder, as ordered.

No. 2   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures that the Mental Health Residential Rehabilitation Treatment Program provides timely therapeutic activity schedules to residents, including weekend treatment activities.

No. 3   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director consults with the Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Office to evaluate whether the resident privileging levels program was congruent with the goals of the Mental Health Residential Rehabilitation Treatment Program, and take action as necessary.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-05228-279 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, ensure community care provider participation is effectively monitored at the local level to mitigate the risk of unidentified gaps in specialty care coverage.

No. 2   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, ensure the Veterans Integrated Service Network 6 Claims Adjudication and Reimbursement office identify and dedicate the appropriate number of staff needed to timely process Non-VA Care medical claims.

No. 3   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, ensure the Veterans Integrated Service Network 6 Claims Adjudication and Reimbursement office implements specific controls to ensure staff are not inaccurately rejecting Non-VA care claims, or rejecting claims for the wrong reasons.

No. 4   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, implement controls to ensure VA staff timely resolve medical claim inquiries from community providers.

No. 5   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, implement oversight procedures to ensure community care contractors effectively notify community providers when they reject their claims.

No. 6   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, implement oversight procedures to ensure community care contractors effectively resolve medical claim inquiries from community providers.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01963-284 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director takes administrative action in relation to primary care provider 1, as appropriate.

No. 2   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director ensures patients impacted by blood pressure falsifications are evaluated and followed up.

No. 3   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director evaluates and takes appropriate action in relation to the four cases discussed in this report.

No. 4   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director develops processes to ensure the integrity of Veterans Health Administration Support Service Center data that supports performance metrics.

No. 5   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director ensures the development of policies and procedures governing primary care-based blood pressure readings and documentation.

No. 6   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director evaluates the practices of primary care provider 1’s licensed practical nurse, and takes appropriate administrative action, if indicated.

No. 7   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director requires retraining of Berea Community Based Outpatient Clinic staff on documentation requirements.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-03347-285 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director ensures a review of Community Living Center 3’s 24-Hour Observation Flow Sheets is completed to determine the accuracy of documentation entered by all shifts for the past three months, beginning with the date of receipt of this report, and initiates an action plan to correct identified deficiencies.

No. 2   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director makes certain that an updated quality management review is completed, to include evaluation of medication management throughout the discussed patient’s admission, and disseminates findings to staff and service lines involved in the care of the patient.

No. 3   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director ensures that the Office of General Counsel is consulted regarding the patient’s missed anticoagulation doses to determine if institutional disclosure to the patient’s family is appropriate per Veterans Health Administration Handbook 1004.08, Disclosure of Adverse Events to Patients.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-03347-290 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director makes certain that staff conduct post-Code Blue debriefings as required and that compliance is monitored.

No. 2   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director ensures the collection, review, and analysis of data following each Emergency Response Team event response and that those involving resuscitative care are reviewed by the Facility Cardiopulmonary Resuscitation Committee, and that compliance is monitored.

No. 3   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director confirms that a review of the Community Living Centers’ meal staffing process is performed to evaluate the need for designation of a staff person responsible for assigning (both nurse and interdisciplinary team) and monitoring staffing levels in the dining hall throughout meal times and takes appropriate action.

No. 4   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director completes a review of the meal delivery process in the CLCs to confirm and document menu selection and diet type at the time that meal trays are served to the patient and makes policy updates, if warranted.

No. 5   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director verifies that Community Living Centers’ safety rounds are conducted and documented, as required, and that compliance is monitored.

No. 6   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director confers with Office of General Counsel to determine if an institutional disclosure of Patient A’s care is warranted.

No. 7   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director obtains peer reviews of the care provided by practitioners (including supervisors in the case of the resident physicians) during the emergency management of Patient A while in the Community Living Center and Emergency Department.

No. 8   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director reviews and updates, as warranted, Facility policies and practices related to emergency medical response (such as obtaining emergent intravenous access) and adequate medical oversight, and all staff (including resident physicians) complete training and compliance is monitored.

No. 9   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 2 Director oversees and provides assistance to the Northport VA Medical Center Director in the review and update of Facility policies and practices on emergency medical response and adequate medical oversight.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-03347-293 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director completes a full review of Community Living Center nurse staffing to ensure authorized full-time employee equivalents align with census and recommended nursing hours per patient day and that modifications (if any) are reflected on the Nursing Service organizational chart.

No. 2   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director continues efforts to recruit and hire for Community Living Center nursing vacancies and ensures that, until optimal staffing is attained, alternate staffing strategies are consistently available to meet resident care needs.

No. 3   to Veterans Health Administration (VHA)

The Northport VA Medical Center Director reviews and identifies processes that improve management of overtime practices to ensure quality of care and responsible use of financial resources and determines if actions need to be taken.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-00613-275 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that an interdisciplinary Facility group review Utilization Management data and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Service Chiefs consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Facility Director ensures that the duties of the controlled substance coordinator and alternate controlled substance coordinator are included in the employees’ position descriptions or functional statements and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures controlled substance inspectors complete controlled substance order verifications and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures staff link the mammography results to the radiology order and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01018-281 | Summary | Report

Recommendations (11)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff 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 implementation of root cause analysis actions and provides feedback of results to the reporting individuals or departments and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to the Facility leaders and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Service Chiefs complete and report Focused and Ongoing Professional Practice Evaluations to the Professional Standards Board for determination of provider privileges and monitors the Service Chiefs’ compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures environment of care rounds are conducted in patient care areas of the Facility at the required frequency and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures a proactive pest control management program is in place throughout the Facility and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

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

No. 8   to Veterans Health Administration (VHA)

The Associate Director ensures that a consistent mechanism or method is in place for clinical staff to be confident that patient care equipment is safe and functional and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Associate Director ensures the mental health seclusion room flooring provides cushioning.

No. 10   to Veterans Health Administration (VHA)

The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.

No. 11   to Veterans Health Administration (VHA)

The Chief of Staff ensures that geriatric evaluation performance improvement activities are reviewed by a Facility leadership board and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 16-00538-282 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that VA facilities have formal processes in place for providers to access state prescription drug monitoring programs to reconcile medications dispensed by private providers and those dispensed by VA, and that this process is in compliance with the providers’ state licensing requirements.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the use of facility-specific panel readjustments or other means of increasing resources for primary care providers who manage chronic pain conditions for a significant proportion of his/her panel and takes action as appropriate.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates and determines the adequacy of the number of pain specialists at each facility through formalized assessments and takes action as appropriate.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that VA facilities without pain specialists have formalized designated resources of pain care provided by providers.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the use of pain assessment tools across the Veterans Health Administration to ensure that those tools used by facilities provide information that improves oversight to patients who are treated for chronic pain conditions.

No. 6   to Veterans Health Administration (VHA)

The Under Secretary for Health develops a formal evaluation of the provision of pain management services within VA to complement the Opioid Safety Initiative.

No. 7   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that VA’s practice of routine and random urine drug tests both prior to initiating and during take-home opioid therapy to confirm the use of opioids is in alignment with guidelines.

No. 8   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that opioid patients with active (not in remission) substance use disorder undergo urine drug testing and receive treatment for the substance use disorder.

No. 9   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates and determines that VA’s practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with guidelines.

No. 10   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that medication reconciliation is performed to prevent adverse drug interactions.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-00620-277 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly defined timeframes and monitors the clinical managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

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

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures that the Executive Council of Medical Staff uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

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

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures Nutrition & Food Service staff store cleaning solutions separately from food items and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Interim Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and that controlled substances coordinators refrain from conducting routine inspections and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Interim Director ensures that reconciliation of controlled substance returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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