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

Oversight Reports

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that providers document clinical judgement, coordination of care, communication with the patient or referring facility, and an accurate plan of care from initial assessment to procedure for transcatheter aortic valve replacement patients.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

OIG Determination of VHA Occupational Staffing Shortages FY 2017

9/27/2017 | 17-00936-385 | Summary | Report | 4 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Acting Under Secretary for Health ensure that the Veterans Health Administration implements staffing models for critical need occupations.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Acting Under Secretary for Health review the Veterans Health Administration report on regrettable losses and implement effective measures to reduce such losses.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Acting Under Secretary for Health continue incorporating data that predict changes in veteran demand for health care into its staffing model.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Acting Under Secretary for Health continue assessing the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that primary care appointment scheduling processes are assessed and action is taken to ensure timely access for new and established patients.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Captain James A. Lovell Federal Health Care Center Director ensure that patients in the Community Living Center receive appropriate fall risk ratings and individualized fall intervention plans.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Captain James A. Lovell Federal Health Care Center Director ensure compliance with Veterans Health Administration policies on Emergency Department provider coverage.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Captain James A. Lovell Federal Health Care Center Director ensure compliance with Veterans Health Administration and Captain James A. Lovell Federal Health Care Center policies on hand hygiene practices.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Amarillo VA Health Care System Director ensure that community based outpatient clinics are appropriately staffed to provide care.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Amarillo VA Health Care System Director ensure that managers conduct clinical reviews of the three Clovis Community Based Outpatient Clinic patients discussed in this report to determine whether a delay in follow-up adversely affected their outcomes and take action as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that Urgent Care Clinic providers consistently transfer stroke patients to an appropriate acute care facility in accordance with Veterans Health Administration and facility policies and procedures.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that the Peer Review Committee follows Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that facility managers clinically review the records of the 13 patients not transferred to the non-VA acute care hospital, approximately 2.5 miles away, to determine whether patient harm occurred and take action as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network 12 Director improve oversight of the Dental Clinic by performing unannounced inspections that include opportunities to interview staff privately regarding any concerns.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Facility Director improve oversight of the Dental Clinic by conducting unannounced, detailed inspections to ensure adherence to Veterans Health Administration and facility infection control standards, patient safety guidelines, and other pertinent dental policies and procedures.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility Director conduct training on when it is appropriate to report issues relating to the quality of healthcare or patient safety issues and the various options on where to report.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director consult with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action, if any, for staff who failed to report the reuse of unsterile burs on patients.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure Environment of Care rounds are scheduled when all areas of the Dental Clinic are available to be inspected.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that consult clinical reviews and appointment scheduling for patients are conducted in compliance with Veterans Health Administration directives and system policies.

No. 2   to Veterans Health Administration (VHA)

We recommended that Physical Medicine and Rehabilitation Services have sufficient staffing to arrange for timely consultations and appointments within the service.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility staff who schedule Physical Medicine and Rehabilitation Services patient appointments receive annual scheduling competencies to ensure understanding of the correct process for compliance with Veterans Health Administration directives and staff are monitored for compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Filter Options

Use the controls below to filter the list of oversight reports. Click on the headings to view the filter choices.

Current Filter

  • Report Type: Healthcare Inspections

Records 1 - 10 of 652 oversight reports that match your filter criteria.

10/16/2017 11:13:56 PM


Date RangeRemove

Limits the list of reports to those published in the date range specified below.

Report LocationRemove

Limits the list of reports to those pertaining to the cities selected below. Hold down the control key to select multiple values or to toggle an individual value on or off.

VA Administration/Staff OfficeRemove

Limits the list of reports to those pertaining to the VA offices selected below. Hold down the control key to select multiple values or to toggle an individual value on or off.

Report TypeRemove

Limits the list of reports to the report types selected below. Hold down the control key to select multiple values or to toggle an individual value on or off. For a description of the types of oversight reports published by the OIG, please visit our Reports and Publications homepage.

OIG Report AuthorRemove

Limits reports to those authored by specific OIG elements. Hold down the control key to select multiple values or to toggle an individual value on or off.

Report NumbersRemove

Helpful for finding reports if you know the report number. Separate multiple values with semicolons.

Search TermsRemove

Limit the results to reports that match your search terms.

Recommendation StatusRemove

Limits reports to those with open or closed recommendations.

Recommendation Action OfficeRemove

Limits reports to those with recommendations specific to the following VA Offices

Displaying records at a time.