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

OIG Reports

| 18-01766-78 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Director ensures that the nurse practitioner referenced in this report has appropriate competencies to perform current duties.

No. 2   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Directoridentifies and implements a reliable tool for coordinating the non-VA care coordination process and monitors the tool for consistency.

No. 3   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Directorconducts a compliance review of the clinically indicated dates used by providers referring patients to Integrated Health Service to determine adherence to Veterans Health Administration Directive 1232 (1), Consult Processes and Procedures, and implements a plan for improvement, if warranted.

No. 4   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Directorensures that non-VA care coordination appointments are scheduled within 30 days of the clinically indicated date and monitors performance.

No. 5   to Veterans Health Administration (VHA)

TheOrlando VA Medical Center Director conducts a review of Integrated Health Services workload demand and available staff and takes action, as appropriate, to ensure staffing allows for consults to be acted upon within Veterans Health Administration consult timeliness standards.

No. 6   to Veterans Health Administration (VHA)

The Orlando VA Medical Center Director implements a process for measuring the timeliness of approvals for requests for additional services and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-05742-66 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures evaluation of inaccuracies and risks involved with use of bulk bottles of controlled liquid solutions, takes actions as needed to reduce risks, and monitors effectiveness of actions taken.

No. 2   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director ensures the interdisciplinary review of unit dose and multi-dose oxycodone solution dispensing and administration, takes actions as appropriate, and monitors effectiveness of actions.

No. 3   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director consults with the Office of Chief Counsel regarding whether an institutional disclosure is appropriate for this patient’s death and takes actions as needed.

No. 4   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director conducts a quality review of the patient’s death and takes actions as needed.

No. 5   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director ensures that nursing staff follow facility policy in the hiring of nurses.

No. 6   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director ensures evaluation and revision as needed of facility nurse competency processes on the hospice unit for high-alert medications and monitors effectiveness of actions taken.

No. 7   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director evaluates the care provided to other patients by the nurse who administered the potential overdose for other possible practice issues.

No. 8   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director ensures evaluation by nursing leaders to determine the need for reporting the nurse who administered the potential overdose to the State Licensing Board and takes steps as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 16-04396-44 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Information and Technology (OIT)

The Assistant Secretary for Information and Technology consults with the Office of Management and Budget for additional guidance on determining whether servers the Office of Information Technology excluded from inventories were subject to the Data Center Optimization Initiative guidance in its June 2017 policy memo, Data Center Development Freeze.

No. 2   to Office of Information and Technology (OIT)

The Assistant Secretary for Information and Technology ensures the facility Chief Information Officers effectively communicate Data Center Optimization Initiative requirements to all staff responsible for VA data centers.

No. 3   to Office of Information and Technology (OIT)

The Assistant Secretary for Information and Technology develops a mechanism for validating the accuracy and completeness of reported data center information to the Office of Information and Technology National Data Center Program team.

No. 4   to Office of Information and Technology (OIT)

The Assistant Secretary for Information and Technology establishes a process to facilitate a VA-wide inventory of data centers, including those outside the direct control and ownership of the Office of Information Technology.

No. 5   to Office of Information and Technology (OIT)

The Assistant Secretary for Information and Technology ensures VA’s Data Center Optimization Initiative strategic plan is complete and includes a timeline for achieving OMB’s cost savings targets, data center closures targets, and optimization performance metrics for energy metering and power usage effectiveness.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-05410-62 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Salem VA Medical Center Director ensures that patients impacted by blood pressurefalsifications are evaluated and receive follow-up as clinically indicated.

No. 2   to Veterans Health Administration (VHA)

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

No. 3   to Veterans Health Administration (VHA)

The Salem VA Medical Center Director directs the development of policies and proceduresthat ensure compliance with clinical quality reporting requirements as outlined in the Danvillecommunity based outpatient clinic contract.

No. 4   to Veterans Health Administration (VHA)

The Salem VA Medical Center Director evaluates the adequacy of the Chief of Staff’s andChief of Primary Care’s responsiveness to the VA Office of Inspector General’s concerns andtakes action as appropriate.

No. 5   to Veterans Health Administration (VHA)

The Salem VA Medical Center Director ensures the Contracting Officer’s Representativereceives the necessary training to fulfill all required functions and oversight responsibilities.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-01757-50 | Summary | Report

Recommendations (18)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Facility Director ensures that recommended actions from peer reviews and root cause analyses are implemented and monitored for improvement.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors the staff’s compliance.

No. 3   to Veterans Health Administration (VHA)

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

No. 4   to Veterans Health Administration (VHA)

The Facility Director ensures that the Patient Safety Manager provides feedback of root cause analysis results to the reporting individuals or departments and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Focused and Ongoing Professional Practice Evaluations are completed, and that the Professional Standards Board reviews these evaluations in considering whether to continue provider privileges, and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures that safety and infection prevention processes are in place at construction sites and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures that nursing staff dispose of expired or unsealed supplies and monitors the staff’s compliance.

No. 8   to Veterans Health Administration (VHA)

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

No. 9   to Veterans Health Administration (VHA)

The Associate Director ensures all applicable equipment is inspected and identified as safe for patient use and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

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

No. 11   to Veterans Health Administration (VHA)

The Associate Director ensures the furniture in the mental health seclusion room is limited to an appropriate style bed and monitors for compliance.

No. 12   to Veterans Health Administration (VHA)

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

No. 13   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. 14   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 description or functional statement.

No. 15   to Veterans Health Administration (VHA)

The Facility Director ensures that a reconciliation of controlled substance return to pharmacy stock is performed during controlled substance inspections and monitors compliance.

No. 16   to Veterans Health Administration (VHA)

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

No. 17   to Veterans Health Administration (VHA)

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

No. 18   to Veterans Health Administration (VHA)

The Facility Director ensures the Chief of Health Information Management facilitate the timely scanning of clinical reports into the electronic health record and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-05264-58 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The System Director ensures completion of evaluations of Patients B and C to determine whether opportunities for more timely diagnosis of deep vein thrombosis existed, and takes action if indicated.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-03499-20 | Summary | Report

Recommendations (12)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration ensures that the VA Police Service publishes written operational policies and procedures designed to regulate essential functions of the Executive Protection Division, including threat assessment processes, motorcade operations, security drills, equipment maintenance, use of personal protective gear, and other topics deemed appropriate after consultation with executive protection experts.

No. 2   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration makes certain that an adequate threat assessment is developed and kept current for each principal secured by the Executive Protection Division.

No. 3   to Office of Human Resources and Administration; Office of Operations, Security & Preparedness

The Acting Assistant Secretary for Human Resources and Administration, along with the Director of the Office of Security and Law Enforcement and the Director of Police Service, reviews the U.S. Secret Service recommendation made to VA in April 2017 about shift scheduling and either implements the recommendation or thoroughly documents the reasons for non-implementation.

No. 4   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration confers with the VA Offices of General Counsel and Accountability and Whistleblower Protection to ensure that bills of collection are issued to agents identified as receiving improper payments of overtime or travel reimbursement and to determine the appropriate administrative action to take, if any, against agents and supervisors who submitted or approved falsified time cards.

No. 5   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against personnel involved with the nonsecure transmission of the former VA Secretary’s anticipated movements to individuals external to VA who had no need to know.

No. 6   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration ensures that the Executive Protection Division institutes procedures to report and appropriately address security lapses, such as those described in this report, and holds agents accountable for individual conduct that contributes to such lapses.

No. 7   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration establishes written procedures for documenting the review and approval of employee overtime within the Executive Protection Division and ensures compliance.

No. 8   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration assesses and takes remedial action, if necessary, to make certain that Executive Protection Division staff use parking and transit benefits in accordance with VA policy.

No. 9   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration confers with the Offices of General Counsel and Accountability and Whistleblower Protection to determine whether any agents inappropriately accepted transit benefits while using VA parking spaces, and if so, determine the appropriate administrative action to take, if any.

No. 10   to Office of Human Resources and Administration; Office of General Counsel (OGC)

The Acting Assistant Secretary for Human Resources and Administration works with the Offices of General Counsel and Accountability and Whistleblower Protection to institute procedures for an ombudsman or similar function that will enable the Executive Protection Division agents to address management disputes without needing to involve the VA Secretary.

No. 11   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration consults with the Office of General Counsel to confirm that the Executive Protection Division and the Office of Secretary have written policies and procedures reasonably designed to ensure that the principal under protection receives a thorough orientation to the appropriate uses of the Division’s services.

No. 12   to Office of Human Resources and Administration

The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to provide adequate mechanisms and training for all staff within the Office of Operations, Security, and Preparedness, including the Executive Protection Division, that ensure allegations of perceived misconduct by the VA Secretary can be appropriately addressed without the threat of retaliation.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 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.

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