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

OIG Reports

| 19-08374-112 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures the clarification of policy regarding emergent mental health services extension request procedures including expected timeframes and patient notification processes.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health expedites the establishment of policy regarding follow-up of patients identified by the Recovery Engagement and Coordination for Health –Veterans Enhanced Treatment program and no longer receiving Veterans Health Administration services.

No. 3   to Veterans Health Administration (VHA)

The Coatesville VA Medical Center Director ensures compliance with the 90-day emergent mental health services extension request policies and procedures, as required by the Veterans Health Administration.

No. 4   to Veterans Health Administration (VHA)

The Coatesville VA Medical Center Director evaluates the Grant and Per Diem Program medical emergency procedures, seeks consultation with relevant subject matter experts including IntegratedEthics®, and takes action as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-07682-103 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director makes certain the Chief of Staff ensures research providers take action based on stress-test results to include coordination of care and notification to primary providers as warranted.

No. 2   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director ensures that a full retrospective review of patients enrolled, to date, in the Arm Exercise Versus Pharmacologic Stress Testing for Clinical Outcome Prediction study with positive stress tests received communication of their test result and follow-up care if indicated.

No. 3   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director ensures that a review of Patient A’s case is completed to determine if disclosure is warranted.

No. 4   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director makes certain that the Institutional Review Board ensures adherence to the research study plan related to communication to the primary provider of patient enrollment in the study.

No. 5   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director ensures alignment of content for the regadenoson stress test protocols and education provided to staff and healthcare trainees.

No. 6   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director ensures the stress test laboratory regadenoson protocol meets VA St. Louis Health Care System Memorandum 00-34 requirements.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-09436-108 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Black Hills Healthcare System Director complies with Veterans Health Administration requirements that Level 1 and 2 facilities have an assistant chief of Sterile Processing Services on staff.

No. 2   to Veterans Health Administration (VHA)

The VA Black Hills Healthcare System Director ensures that Sterile Processing Services leaders track changes to manufacturer’s instructions, updates standard operating procedures, retrains staff as needed, and monitors compliance with Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

The VA Black Hills Healthcare System Director ensures that Sterile Processing Services leaders maintain up-to-date staff competencies for reprocessing, and monitors compliance with Veterans Health Administration policy.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 19-05866-82 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The OIG recommended that the executive director of VHA Procurement establish effective and consistent quality assurance reviews, especially for contracts deemed higher risk, to ensure all closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended that the executive director of VHA Procurement ensure all contracting officers receive standardized training regarding the Veterans Health Administration procurement manual closeout procedures, including the correct use of closeout procedures for contracts that are awarded using Federal Acquisition Regulation part 8 and simplified acquisition procedures.

No. 3   to Veterans Health Administration (VHA)

The OIG recommended that the executive director of VHA Procurement ensure the contract files for the 40 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and Veterans Health Administration procurement manual.

Total Monetary Impact of All Recommendations

Open: $ 6,840,219.00
Closed: $ 0.00

| 19-07090-90 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director reviews and develops cardiology recruitment and retention processes to reach the approved staffing level.

No. 2   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director explores the possible reasons for difficulties recruiting and retaining cardiologists and takes action to resolve identified issues.

No. 3   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director ensures that facility staff understand the Veterans Health Administration policy regarding authorized and unauthorized patient wait lists, and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director ensures facility managers train staff regarding the consult process and wait list policies, and monitors compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01275-89 | Summary | Report

Recommendations (13)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director identifies facility resources and other means for provider education and training to strengthen skills when deficiencies in care are identified during peer reviews.

No. 2   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures that Peer Review Committee meeting minutes document reasons for changes to peer review levels, and that changes are consistent with its review of relevant aspects of clinical care.

No. 3   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures review of procedures to make certain gastroenterology staff coordinate care with referring providers and provide staff training on care coordination procedures as needed.

No. 4   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director makes certain that Community Living Center staff utilize the Situation, Background, Assessment, and Recommendation communication tool and document transfers to the Emergency Department in accordance with Dayton VA Medical Center policy.

No. 5   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director considers consolidating Medical Center policies related to patient transfers and transports to and from the Emergency Department into one policy to provide clear guidance to staff to effect timely transfers.

No. 6   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures consistent implementation of standing orders in the Emergency Department.

No. 7   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director verifies policies and procedures are in place for monitoring of critically ill patients to track deterioration and need for intervention in the Emergency Department and during transport, and monitor compliance.

No. 8   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures that handoff communication between Emergency Department providers is accurate and documented in the electronic health record during transitions in care in accordance with Dayton VA Medical Center policy, and compliance is monitored.

No. 9   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures review of results from the revision of the Dayton VA Medical Center policy on threshold for peer review findings to trigger management reviews in order to confirm the revised policy is appropriately sensitive to identify provider practice issues that constitute patient safety concerns, and revise the policy if needed.

No. 10   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director confirms all code carts in the Emergency Department are processed and secured consistent with Dayton VA Medical Center policy.

No. 11   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures Emergency Department supplies are secured and maintained consistent with Dayton VA Medical Center policy.

No. 12   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director ensures continued monitoring and compliance with bar code medication administration policy in the Community Living Center.

No. 13   to Veterans Health Administration (VHA)

The Dayton VA Medical Center Director reviews document management procedures for professional practice evaluations and takes actions as needed to comply with the VA Records Control Schedule.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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