Oversight Reports

No. 1   to Veterans Health Administration (VHA)

The Facility Director ensures all patient incidents are entered into the VHA Patient Safety Information System and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes 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 Associate Director ensures required team members participate on environment of care rounds and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Director ensures that the Alternate Control Substance Coordinator’s position description or functional statement includes an addendum for the Control Substance Coordinator’s duties and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Director ensures that all Controlled Substance Inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures Service Chiefs complete required elements of Focused Professional Practice Evaluations for review by the Medical Executive Board and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Service Chiefs include all required elements for Ongoing Professional Practice Evaluations and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

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

No. 4   to Veterans Health Administration (VHA)

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

No. 5   to Veterans Health Administration (VHA)

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

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures providers complete suicide risk assessments, within the required timeframe, for patients with positive Post-Traumatic Stress Disorder screens and monitors providers’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures that geriatric evaluation program performance improvement activities are presented to an appropriate leadership board and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff ensures that clinicians accurately identify and implement the Geriatric Evaluation plan of care interventions and monitors compliance.

No. 1   to Veterans Health Administration (VHA)

The Facility Director requires the Patient Safety Manager to ensure completion of the required minimum of eight root cause analyses each fiscal year and monitors the Patient Safety Manager’s compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that service chiefs include service-specific performance data for Ongoing Professional Practice Evaluations and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

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

No. 4   to Veterans Health Administration (VHA)

The Associate Director requires the Nutrition and Food Services Chief to develop and implement a Hazard Analysis Critical Control Point Food Safety plan and monitors the Chief’s compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director requires the Nutrition and Food Services Chief to establish a food service-focused inspection process to occur at no less than quarterly intervals and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director requires the Nutrition and Food Services Chief to ensure that food items are properly labeled and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures that providers complete suicide risk assessments, within the required timeframe, for patients with positive post-traumatic stress disorder screens and monitors the providers’ compliance.

No. 8   to Veterans Health Administration (VHA)

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

No. 1   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, develops a timeline to reduce improper payments under the 10 percent threshold for the Beneficiary Travel; Communications, Utilities, and Other Rents; Medical Care Contracts and Agreements; Prosthetics; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding and recommendation for the Purchased Long Term Services and Support and VA Community Care programs from our FY 2015 and 2016 reports.

No. 2   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, implements steps to achieve stated reduction targets for the Beneficiary Travel; Civilian Health and Medical Program of the Department of Veterans Affairs; Purchased Long Term Services and Support; Supplies and Materials; and VA Community Care Programs and activities. This is a repeat finding for all five programs from our FY 2016 report.

No. 3   to Veterans Benefits Administration (VBA)

The Executive in Charge, Veterans Benefits Administration, implements steps to achieve reduction targets for the Pension and Post-9/11 GI Bill Programs.

No. 4   to Veterans Health Administration (VHA)

The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, implement procedures to ensure thorough testing of sample items used to estimate improper payments for Supplies and Materials purchases under indefinite delivery contracts.

No. 5   to Veterans Benefits Administration (VBA)

The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly. This is a repeat recommendation from our FY 2016 report.

No. 6   to Veterans Benefits Administration (VBA)

The OIG recommended the Executive in Charge, Veterans Benefits Administration, continue to report statutory barriers preventing complete resolution of drill pay improper payments in future Agency Financial Reports until resolved.

No. 1   to Veterans Health Administration (VHA)

The Lexington VA Medical Center Director develops a clear action plan to resolve the Podiatry Department work environment issues and monitors compliance to ensure patient safety.

No. 1   to Veterans Health Administration (VHA)

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

No. 2   to Veterans Health Administration (VHA)

The Deputy Director ensures all medical equipment at the South Sound VA Clinic is identified as safe for patient use and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Infection Control Committee consistently documents discussions of on-going construction activities and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Assistant Director ensures temperature monitoring occurs in dry food storage areas and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.

No. 1   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure clinicians and Beneficiary Travel Office staff comply with Veterans Health Procedure Guide 1601B.05 eligibility requirements for authorizing Special Mode of Transportation services.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health modify Veterans Health Administration Procedure Guide 1601B.05 to require the Beneficiary Travel Office staff to verify beneficiaries attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.

No. 3   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health require Veterans Integrated Service Networks to implement periodic reviews to ensure VA Medical Centers comply with Veterans Health Administration policies for verifying beneficiaries listed on vendor invoices had been properly authorized for Special Mode of Transportation services or attended medical appointments prior to approving payment of Special Mode of Transportation vendor invoices.

No. 4   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health ensure the Improper Payments Elimination and Recovery Act reports provided to Veterans Integrated Service Networks are modified to include Special Mode of Transportation information specific to vendor payments by VA Medical Centers.

No. 5   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health implement use of Centers for Medicare and Medicaid Services Rates when savings can be achieved for Special Mode of Transportation ambulance services in accordance with 38 U.S.C. Section 111(b)(3)(C).

No. 6   to Veterans Health Administration (VHA)

The OIG recommended the Under Secretary for Health implement controls to prevent beneficiaries using Special Mode of Transportation services from also obtaining mileage reimbursement for the same appointment(s).

No. 1   to Veterans Benefits Administration (VBA); Office of Acquisitions, Logistics, and Construction (OALC); Office of General Counsel (OGC)

The OIG recommended the Executive in Charge for Benefits coordinate with the Head of VA Contracting Activity and the Office of General Counsel to determine what actions need to be taken to remedy the unauthorized commitment.

No. 2   to Veterans Benefits Administration (VBA)

The OIG recommended the Executive in Charge for Benefits obtain appropriate funding for all future information technology costs.

No. 3   to Veterans Benefits Administration (VBA); Office of Management; Office of Information and Technology (OIT); Office of General Counsel (OGC)

The OIG recommended the Executive in Charge for Benefits coordinate with the Office of Information Technology, the Office of Management, and the Office of General Counsel to make accounting adjustments to debit the information technology account that should have been used and credit the general operating expense account that was inappropriately used, determine whether Antideficiency Act violations occurred, and report the violations as appropriate.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that providers establish clinical signs and symptoms consistent with androgen deficiency, prior to testing patients’ testosterone level for confirmation in alignment with Veterans Health Administration guidance.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that providers biochemically confirm hypogonadism through repeated testosterone testing prior to initiation of testosterone replacement therapy in alignment with Veterans Health Administration guidance.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that providers determine whether the etiology of hypogonadism is primary or secondary, prior to testosterone replacement therapy initiation in alignment with Veterans Health Administration guidance.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that providers discuss and document the risks and benefits of testosterone therapy with patients prior to initiation in alignment with Veterans Health Administration guidance.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that providers assess and document patients’ symptoms improvement and adverse effects within 3–6 months of initiation before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.

No. 6   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that providers monitor patients’ hematocrit levels within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.

No. 7   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that providers assess and document patients’ adherence to therapy and perform testosterone level test within 3–6 months of initiation, before continuing testosterone replacement therapy in alignment with Veterans Health Administration guidance.