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

OIG Reports

| 18-01154-27 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

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

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures service chiefs complete all required elements, including minimum required specialty criteria for Ongoing Professional Practice Evaluations and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Deputy Director ensures that a safe and clean environment is maintained throughout the Facility and Westmoreland County Community Based Outpatient Clinic and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Deputy Director ensures the flooring in the mental health seclusion rooms provides cushioning.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01161-28 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that Facility managers develop and implement a comprehensive Facility policy on the use and care of central lines and monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-01007-01 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Clarify program responsibilities between the Veterans Health Administration and theOffice of Operations, Security, and Preparedness, and evaluate the need for a centralizedmanagement entity for the security and law enforcement program across all medicalfacilities.

No. 2   to Veterans Health Administration (VHA)

Ensure police staffing models are implemented for determining facility-appropriate levelsfor officers at medical facilities.

No. 3   to Veterans Health Administration (VHA)

Make certain medical facilities use strategies to address police staffing challenges such ashaving documented recruitment plans for police officer positions that include adetermination of the need for special salary rates and incentives.

No. 4   to Veterans Health Administration (VHA)

Assess the staffing levels for the Office of Security and Law Enforcement policeinspection program, and authorize and provide sufficient resources to conduct timelyinspections of police units at medical facilities to help identify program complianceissues.

No. 5   to Veterans Health Administration (VHA)

Ensure procedures are developed for appropriately handling VA police investigations ofmedical facility leaders.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-02163-23 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health Care System Director ensures that patients are assigned primary care providers, as required by Veterans Health Administration policy, and that the assignments are monitored for compliance.

No. 2   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health System Director ensures that patients with Joint Ambulatory Care Center dermatology consults are scheduled as required by Veterans Health Administration policy and within the Veterans Health Administration consult timeframe, and that the scheduling process is monitored for compliance.

No. 3   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health Care System Director ensures that system managers review dermatology and non-VA care scheduling staffing levels, and develop an action plan to address recommendations, if any, from the staffing level reviews.

No. 4   to Veterans Health Administration (VHA)

The Gulf Coast Veterans Health System Director takes appropriate action as related to Patient B’s physicians’ improper electronic health record documentation as discussed in this report.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01142-25 | Summary | Report

Recommendations (11)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures that service chiefs communicate to the Peer Review Committee the completion of individual improvement actions and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures that all Focused Professional Practice Evaluations include clearly delineated timeframes and monitor compliance.

No. 3   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. 4   to Veterans Health Administration (VHA)

The Associate Director ensures that staff store clean and dirty equipment separately and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures the mental health unit seclusion room toilet is shatterproof.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures that environment of care rounds are conducted as required at the McComb Community Based Outpatient Clinic and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Associate Director ensures that staff at the McComb Community Based Outpatient Clinic remove all expired, damaged, and/or contaminated medications and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The Associate Director ensures the McComb Community Based Outpatient Clinic managers maintain a safe and clean environment and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Associate Director ensures that shelving is clean and bottom storage shelves are solid at the McComb Community Based Outpatient Clinic and monitors compliance.

No. 10   to Veterans Health Administration (VHA)

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

No. 11   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers offer and refer patients with positive posttraumatic stress disorder screens for further diagnostic evaluations and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01144-24 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from social work and the Chief Business Office revenue utilization review and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures Ongoing Professional Practice Evaluations utilize assessments by providers with similar training and privileges and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures managers clearly mark and securely store medical biohazardous waste and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures the Police and Security Operations document response time to panic alarm testing at the locked mental health unit and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures that the Emergency Management Plan is reviewed annually and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Facility Director ensures that the Quality Council maintains oversight of all geriatric evaluation program performance improvement activities and monitors compliance.

No. 7   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.

| 18-01145-26 | Summary | Report

Recommendations (8)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 delineated timeframes and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director ensures the VA Police regularly test panic alarms at the Northwest Las Vegas VA Clinic and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing in the locked mental health unit 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 addressed and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures controlled substance monthly inspection dates are randomly selected to avoid distinguishable patterns and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Facility Director ensures that controlled substances inspectors perform reconciliation of controlled substance refills to automated dispensing cabinets in patient care areas and returns to pharmacy stock and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Facility Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The Facility Director ensures that Geriatrics and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 16-00862-179 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits negotiates an amendment to State Approving Agency contracts to clarify requirements for program approvals and require, subject to the availability of resources, quarterly samples and reviews and evaluations of supporting documentation for State Approving Agency approvals to ensure approved programs meet Title 38 of the United States Code requirements.

No. 2   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits negotiates amendments to State Approving Agency contracts that, subject to available resources, require the State Approving Agencies to periodically reapprove programs and evaluate program changes and other operational changes, such as advertisement practices, that may affect a program’s continued eligibility and compliance with Title 38 of the United States Code.

No. 3   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits refers schools identified during the audit with potentially erroneous, deceptive, or misleading advertising practices to the Federal Trade Commission for it to decide whether any further reviews or actions are needed.

No. 4   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits revises and strengthens compliance surveys to improve the assessment of program eligibility and compliance survey quality reviews to include the review of supporting documentation and an independent assessment of the quality of the completed compliance surveys.

No. 5   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits negotiates an amendment to the State Approving Agency contracts to establish quality assurance metrics and ensure the Veterans Benefits Administration collects and uses quality assurance data from its reviews of the State Approving Agencies’ approvals, monitoring, and compliance surveys in its annual evaluations of the State Approving Agencies.

No. 6   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits assesses whether funding for State Approving Agencies is sufficient to ensure the adequate review, approval, and monitoring of programs, in conjunction with the establishment of a contract to update the State Approving Agency funding allocation model.

Total Monetary Impact of All Recommendations

Open: $ 2,300,000,000.00
Closed: $ 0.00

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