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

OIG Reports

| 21-00267-290 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures disclosure of adverse events that require an institutional disclosure.

No. 2   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths monthly.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide prevention safety plans.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System include information regarding patients’ right to appeal the orders and the appeals process.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 21-00274-289 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines additional reasons for noncompliance and ensures the Surgical Workgroup conducts a monthly review of surgical deaths.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members participate in disruptive behavior event reviews.

No. 3   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-02014-270 | Summary | Report

Recommendations (22)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The District Director determines reasons clinical and administrative quality reviews were not completed and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The District Director evaluates the clinical and administrative quality review report approval process to determine if a timeliness measure is needed and takes action as indicated.

No. 3   to Veterans Health Administration (VHA)

The District Director determines reasons clinical and administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The District Director evaluates the process for resolution of clinical and administrative quality review deficiencies and takes action as necessary.

No. 5   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with critical incident quality review (currently known as morbidity and mortality review) of a death by suicide, ensures completion includes an evaluation of vet center services to determine if actions are needed to improve the effectiveness of vet center suicide prevention activities, and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts, ensures completion, and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The District Director ensures intake assessments are completed and monitors compliance across all zone vet centers.

No. 8   to Veterans Health Administration (VHA)

The District Director ensures military histories are completed and monitors compliance across all zone vet centers.

No. 9   to Veterans Health Administration (VHA)

The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.

No. 10   to Veterans Health Administration (VHA)

The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including reasons completion dates are unavailable in RCSnet and ensures compliance with standards for timely completion of intake assessments and military histories.

No. 11   to Veterans Health Administration (VHA)

The District Director determines reasons the Clearwater Vet Center did not have nontraditional hours as required and ensures compliance.

No. 12   to Veterans Health Administration (VHA)

The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with the Clearwater, Ocala, Ponce, and Sarasota Vet Centers staff participation on mental health councils, and takes action as indicated to ensure compliance with Readjustment Counseling Service requirements.

No. 13   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with vet centers’ receipt of the monthly Office of Mental Health and Suicide Prevention list of clients with an increased predictive risk for suicide, ensures coordination of care with VA medical facilities for vet center clients on the list, and monitors compliance.

No. 14   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine the reasons updated lists of clients designated as high risk for suicide were not consistently received by vet centers, and ensures a process for vet centers’ receipt of the list in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding.

No. 15   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with a standardized communication and collaboration process between suicide prevention coordinators and vet centers in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding, and initiates action as necessary.

No. 16   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with high risk for suicide flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Sarasota Vet Center, takes action to ensure requirement is met, and monitors compliance.

No. 17   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with processes for completing and tracking four hours of external clinical consultation per month at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures that vet center directors implement processes, and monitors compliance.

No. 18   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures staff supervision occurs as required, and monitors compliance.

No. 19   to Veterans Health Administration (VHA)

The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures chart audits are completed as required, and monitors compliance.

No. 20   to Veterans Health Administration (VHA)

The District Director determines reasons for errors in training assignments and why completed trainings are not being recorded for employees at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures all staff complete mandatory trainings as required, and monitors compliance.

No. 21   to Veterans Health Administration (VHA)

The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.

No. 22   to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Clearwater and Sarasota Vet Centers and ensures all vet center employees safely and securely store protected health information.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-04051-287 | Summary | Report

Recommendations (20)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The District Director determines reasons administrative quality reviews were not completed, ensures completion, and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The District Director evaluates the administrative quality review report approval process to determine if a timeliness measure is needed and takes actions as indicated.

No. 3   to Veterans Health Administration (VHA)

The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The District Director determines reasons for non-participation with the root cause analysis investigation for shared clients with the support Veterans Affairs medical facility and establishes processes to ensure required vet center participation.

No. 6   to Veterans Health Administration (VHA)

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

No. 7   to Veterans Health Administration (VHA)

The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.

No. 8   to Veterans Health Administration (VHA)

The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.

No. 9   to Veterans Health Administration (VHA)

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

No. 10   to Veterans Health Administration (VHA)

The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

No. 11   to Veterans Health Administration (VHA)

The District Director ensures clinical staff consult with the vet center director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required and monitors compliance across all zone vet centers.

No. 12   to Veterans Health Administration (VHA)

The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.

No. 13   to Veterans Health Administration (VHA)

The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on mental health councils at Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.

No. 14   to Veterans Health Administration (VHA)

The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures vet center directors implement processes, and monitors compliance.

No. 15   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with staff supervision provided by the vet center directors at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures staff supervision occurs as required, and monitors compliance.

No. 16   to Veterans Health Administration (VHA)

The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures chart audits are completed as required, and monitors compliance.

No. 17   to Veterans Health Administration (VHA)

The District Director determines reasons why completed trainings are not being recorded for employees at the Alexandria, Laredo, and Mesquite Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.

No. 18   to Veterans Health Administration (VHA)

The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.

No. 19   to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance related to the Mesquite Vet Center’s emergency and crisis plan not containing all required components and ensures compliance.

No. 20   to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Houston Southwest Vet Center and ensures all vet center employees safely and securely store personally identifiable information.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 21-00268-273 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and ensure that staff use the VA Inter-Facility Transfer Form or an equivalent note to document inter-facility transfers.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that referring physicians record all required elements in the electronic health record prior to patient transfers.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.

No. 5   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 21-01805-286 | Summary | Report

Recommendations (23)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The District Director determines reasons clinical quality review remediation plans were not completed, ensures completion, and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The District Director determines reasons administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.

No. 4   to Veterans Health Administration (VHA)

The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

No. 6   to Veterans Health Administration (VHA)

The District Director ensures lethality risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.

No. 7   to Veterans Health Administration (VHA)

The District Director, in collaboration with Readjustment Counseling Service Central Office evaluates the limitations of current tools and tracking methods including why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.

No. 8   to Veterans Health Administration (VHA)

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

No. 9   to Veterans Health Administration (VHA)

The District Director verifies clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.

No. 10   to Veterans Health Administration (VHA)

The District Director confirms clinical staff make timely notification to the suicide prevention coordinator at the support Veterans Affairs medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.

No. 11   to Veterans Health Administration (VHA)

The District Director ensures clinical staff consult with the Vet Center Director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required, and monitors compliance across all zone vet centers.

No. 12   to Veterans Health Administration (VHA)

The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.

No. 13   to Veterans Health Administration (VHA)

The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Central Oregon Vet Center and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.

No. 14   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Bellingham Vet Center, takes action to ensure requirements are met, and monitors compliance.

No. 15   to Veterans Health Administration (VHA)

The District Director determines reasons the Bellingham Vet Center did not have a written crisis plan, ensures requirements related to crisis plans are met and monitors compliance.

No. 16   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Tacoma Vet Center, ensures assignment of a liaison, and monitors compliance.

No. 17   to Veterans Health Administration (VHA)

The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures Vet Center Directors implement processes, and monitors compliance.

No. 18   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures staff supervision occurs as required, and monitors compliance.

No. 19   to Veterans Health Administration (VHA)

The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures chart audits are completed as required, and monitors compliance.

No. 20   to Veterans Health Administration (VHA)

The District Director determines reasons employees at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.

No. 21   to Veterans Health Administration (VHA)

The District Director evaluates and determines reasons for noncompliance with a presentable exterior at the Wasilla Vet Center and ensures all exterior grounds are in good repair.

No. 22   to Veterans Health Administration (VHA)

The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.

No. 23   to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Bellingham and Tacoma Vet Centers and ensures all vet center employees safely and securely store protected health information.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 20-03407-253 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Implement a plan that brings the five new noncompliant land use agreements into compliance with the West Los Angeles Leasing Act of 2016, the draft master plan, and other federal laws, allowing reasonable time to correct deficiencies noted in this report.

No. 2   to Veterans Health Administration (VHA)

Ensure VA’s capital asset inventory accurately reflects all land use agreements lasting six months or longer on the West Los Angeles campus.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 21-00266-281 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Performance Improvement Committee meetings.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.

No. 3   to Veterans Health Administration (VHA)

The System Director evaluates and determines additional reasons for noncompliance and maintains a current written policy to ensure the safe, appropriate, orderly, and timely transfer of patients.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.

No. 5   to Veterans Health Administration (VHA)

The System Director and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that referring physicians identify the receiving physicians on the Inter-Facility Transfer Form or facility-defined equivalent note.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure nurse-to-nurse communication occurs during the inter-facility transfer process.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.

No. 8   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 21-00272-283 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all core members consistently attend Surgical Work Group meetings.

No. 2   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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