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

OIG Reports

| 21-00239-180 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief Medical Officer determines the reason for noncompliance, reviews the credentials file, and approves the VA appointment for physicians who had a potentially disqualifying licensure action.

| 21-00287-194 | Summary | Report

Recommendations (9)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 leaders properly identify adverse events as sentinel events when criteria are met and conduct institutional disclosures, as required.

No. 2   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Health Systems Specialist participates on the VISN Systems Redesign Review Advisory Group.

No. 3   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend Facility Surgical Workgroup meetings.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate all patient transfers.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to receiving facilities during inter-facility transfers.

No. 7   to Veterans Health Administration (VHA)

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

No. 8   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all Employee Threat Assessment Team members complete the required training.

No. 9   to Veterans Health Administration (VHA)

The Medical Center 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.

| 21-00288-175 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met and conduct institutional disclosures as required.

No. 2   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.

No. 3   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and makes certain that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.

No. 4   to Veterans Health Administration (VHA)

The Associate Director, Clinical Services evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.

No. 5   to Veterans Health Administration (VHA)

The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine reasons for noncompliance and ensure staff monitor and evaluate all inter-facility transfers as part of VHA’s Quality Management Program.

No. 6   to Veterans Health Administration (VHA)

The Associate Director, Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.

No. 7   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team meetings are held and members complete training, as required.

No. 8   to Veterans Health Administration (VHA)

The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.

No. 9   to Veterans Health Administration (VHA)

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

| 21-00283-173 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines additional reasons for noncomplianceand ensures that peer reviewers use at least one of the nine aspects of care forevaluations.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures that the Peer Review Committee recommendsimprovement actions for Level 3 peer reviews.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons fornoncompliance and makes certain that the Peer Review Committee completes finalpeer reviews within 120 calendar days from the date it is determined a peer reviewis required, or the System Director approves any necessary extensions in writing.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and make certain that staffmonitor and evaluate all transfers as part of VHA’s Quality Management Program.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders complete all elements of the VA Inter-Facility Transfer Form or afacility-defined equivalent note in the electronic health record.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders send patients’ active medication lists to receiving facilities during inter-facility transfers.

No. 7   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines anyadditional reasons for noncompliance and makes certain that nurse-to-nursecommunication occurs between sending and receiving facilities.

No. 8   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons fornoncompliance and ensures employees complete all required prevention andmanagement of disruptive behavior training based on the risk level assigned to theirwork area.

| 21-00286-163 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Surgical Workgroup Committee meets atleast monthly.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures staff complete mandatory suicide safety plan trainingprior to developing suicide safety plans.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director/Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure staff send activemedication lists to receiving facilities during inter-facility transfers.

No. 4   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures all staff complete the required prevention andmanagement of disruptive behavior training based on the risk level assigned to theirwork area.

| 21-00293-170 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures leaders conduct institutional disclosures for all sentinelevents.

No. 2   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures the Systems Redesign Coordinator participates on theQuality, Safety & Value Council.

No. 3   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Facility Surgical Work Group meets atleast monthly.

No. 4   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures that core members consistently attend Facility SurgicalWork Group meetings.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that the referringphysician completes all required elements of the VA Inter-Facility Transfer Formor facility-defined equivalent note.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and make certain that requiredrepresentatives attend the Disruptive Behavior Committee meetings.

| 21-00240-158 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief Medical Officer evaluates and determines additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.

No. 2   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Emergency Management Committee conducts annual reviews of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and submits the reviews to executive leaders for approval.

No. 3   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and appoints a permanent Veterans Integrated Service Network lead women veterans program manager.

No. 4   to Veterans Health Administration (VHA)

The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that a lead women veterans program manager conducts yearly visits at each facility in the Veterans Integrated Service Network.

| 21-00299-162 | 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 that leaders identify adverse events as sentinel events when criteria are met.

No. 2   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures that leaders conduct institutional disclosures for all sentinel events.

No. 3   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days or approves a written extension request.

No. 4   to Veterans Health Administration (VHA)

The Executive 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. 5   to Veterans Health Administration (VHA)

The Executive Chief of Staff and Associate Director, Patient Services evaluate and determine any additional reasons for noncompliance and ensure that appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note in the electronic health record prior to patient transfers.

No. 6   to Veterans Health Administration (VHA)

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

No. 7   to Veterans Health Administration (VHA)

The Executive Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents decisions to implement Orders of Behavioral Restriction and patients’ notification of the orders in the Disruptive Behavior Reporting System.

No. 8   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.

| 21-00295-161 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Staff attends Facility Surgical Work Group meetings.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Facility Surgical Work Group reviews National Surgery Office surgical quality reports.

No. 3   to Veterans Health Administration (VHA)

The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a written policy is in place 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 Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note to include required elements in the electronic health record prior to patient transfers.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.

No. 7   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between the sending and receiving facility.

No. 8   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 the Prevention and Management of Disruptive Behavior Program representative attends Disruptive Behavior Committee meetings.

No. 9   to Veterans Health Administration (VHA)

The Executive Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the annual Workplace Behavioral Risk Assessment includes participation by VA police and a patient safety representative.

No. 10   to Veterans Health Administration (VHA)

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

| 21-00296-145 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality Leadership Council.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends individual improvement actions, and clinical managers implement the committee’s recommendations.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that staff complete final peer reviews within 120 calendar days from the date it is determined a peer review is required or have a written extension request approved by the Director.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits quarterly summaries of peer review data for review by the Executive Committee of the Medical Staff.

No. 5   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets at least monthly.

No. 6   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.

No. 7   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 make certain all inter-facility transfers are monitored and evaluated as part of the Veterans Health Administration’s Quality Management Program.

No. 8   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.

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