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

OIG Reports

| 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.

| 17-02679-283 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Atlanta VA Health Care System Director ensures that a review is conducted of patients with mammography orders in an active, pending, or scheduled status as of October 28, 2015, to ensure that clinical care was provided and results are documented in the electronic health record.

No. 2   to Veterans Health Administration (VHA)

The Atlanta VA Health Care System Director makes certain that Medical Center Memorandum 11-04, Health Care for Women Veterans, May 17, 2016, is updated to reflect current Facility processes, including but not limited to mammography coordinator responsibilities.

No. 3   to Veterans Health Administration (VHA)

The Atlanta VA Health Care System Director ensures compliance with Veterans Health Administration Directive 1232(1), Consult Processes and Procedures (amended September 23, 2016), including the completion of mammograms by the order date or the date the physician requested the study be completed and that a process is established for review when consults exceed established timeliness thresholds.

No. 4   to Veterans Health Administration (VHA)

The Atlanta VA Health Care System Director improves mammography processes to schedule appointments and receive, account for, scan, upload, and provide external diagnostic imaging results to the appropriate clinical areas and Veterans Health Administration providers and that the process is monitored.

No. 5   to Veterans Health Administration (VHA)

The Atlanta VA Health Care System Director confirms that clinical appropriateness reviews of mammography consults are performed to ensure that the correct imaging study is ordered for the patient’s clinical presentation and that performance of reviews is monitored.

No. 6   to Veterans Health Administration (VHA)

The Atlanta VA Health Care System Director verifies that providers who are trained in provision of women veterans health care are designated as Women’s Health Primary Care Providers, have the required number of women assigned to their panel, and provide gender specific care in accordance with Veterans Health Administration policy.

No. 7   to Veterans Health Administration (VHA)

The Atlanta VA Health Care System Director provides executive level oversight of the Women Veterans Program to ensure that service level functions are coordinated, processes are streamlined, and identified actions are tracked to resolution.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-01823-287 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Health Administration Under Secretary for Health ensures that drug screening guidelines for VA facilities are reviewed to determine if fentanyl should be included in routine urine drug screening, and takes appropriate action.

No. 2   to Veterans Health Administration (VHA)

The Veterans Health Administration Office of Mental Health Services, Substance Use Disorders, Director considers developing and implementing a monitoring program to identify regional trends of drug abuse for facilities.

No. 3   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network 2 Director evaluates laboratory processes for fentanyl test results and takes appropriate action to ensure timely turnaround times and notification of results.

No. 4   to Veterans Health Administration (VHA)

The Bath VA Medical Center Director ensures accurate tracking and monitoring of positive urine drug screening data.

No. 5   to Veterans Health Administration (VHA)

The Bath VA Medical Center Director ensures that all Domiciliary Residential Rehabilitation Treatment Program clinical staff are trained on the interpretation of urine drug screening laboratory results.

No. 6   to Veterans Health Administration (VHA)

The Bath VA Medical Center Director consults with appropriate personnel including ethics, legal counsel, privacy office, suicide prevention, and relevant Veterans Health Administration Program Office Directors to evaluate the risk identification/color-coded sticker system and ensure the practice is consistent with privacy standards and best practices.

No. 7   to Veterans Health Administration (VHA)

The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided personal protective equipment for use while conducting searches of resident belongings and rooms.

No. 8   to Veterans Health Administration (VHA)

The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided training on conducting safe and effective searches of resident rooms and belongings.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-04569-262 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director ensures that the windows of patient care areas remain secure in accordance with Veterans Health Administration Center for Engineering and Occupational Safety and Health guidelines.

No. 2   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director makes certain that the Chillicothe VA Medical Center’s policy for Special Observation is followed and monitors for compliance.

No. 3   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director verifies that training and staff competencies are completed for Prevention and Management of Disruptive Behavior and Special Observation as required.

No. 4   to Veterans Health Administration (VHA)

The Chillicothe VA Medical Center Director confers with the Office of Chief Counsel regarding the notification of the patient’s death and discussion of institutional disclosure with the next-of-kin and takes action as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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