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

OIG Reports

| 18-05130-105 | Summary | Report

Recommendations (1)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits works with the VA Secretary and Chief Financial Officer to take steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for funds already obligated and expended for medical examinations under the Decision Ready Claims program.

Total Monetary Impact of All Recommendations

Open: $ 10,572,000.00
Closed: $ 0.00

| 18-00215-83 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits implement plans to enhance quality assurance by conducting periodic national oversight of deferrals and ensuring local oversight specifically addresses all aspects of the accuracy of deferrals created in the Veterans Benefits Management System.

No. 2   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits establish internal controls documenting Rating Veterans Service Representatives are informed of their mitigated deferrals and corrective action is taken.

No. 3   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits update guidance to clarify why certain reason selections should be made for deferrals, provide training on this guidance, and monitor the effectiveness of the training.

No. 4   to Veterans Benefits Administration (VBA)

The Under Secretary for Benefits establish plans to modify the Veterans Benefits Management System to allow sufficient space for inputting deferral instructions and require claims processors to input references when creating deferrals.

Total Monetary Impact of All Recommendations

Open: $ 0.00
Closed: $ 1,100,000.00

| 17-02629-119 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Phoenix VA Health Care System Director verifies that clinicians document clinical justification for the continued use of restraints and debriefing sessions according to Veterans Health Administration and Phoenix VA Health Care System policy requirements.

No. 2   to Veterans Health Administration (VHA)

The Phoenix VA Health Care System Director makes certain that the Phoenix VA Health Care Patient Safety Observer policy is followed, and compliance is monitored.

No. 3   to Veterans Health Administration (VHA)

The Phoenix VA Health Care System, Director ensures that inpatient mental health unit nurse staffing methodology is conducted as required by Nurse Staffing Methodology for Veterans Health Administration Nursing Personnel Directive.

No. 4   to Veterans Health Administration (VHA)

The Phoenix VA Health Care System, Director confirms that mental health staff receive mandated training at required intervals including training for patients with dementia as appropriate, and compliance is monitored.

No. 5   to Veterans Health Administration (VHA)

The Phoenix VA Health Care System Director verifies that the inpatient mental health unit is cleaned on a regular basis and compliance is monitored.

No. 6   to Veterans Health Administration (VHA)

The Phoenix VA Health Care System Director ensures that the environment on the inpatient mental health unit is a home-like therapeutic setting as required by Veterans Health Administration Inpatient Mental Health Services Handbook.

No. 7   to Veterans Health Administration (VHA)

The Phoenix VA Health Care System Director ensures that Phoenix VA Health Care System staff enter complaints into the Patient Advocate Tracking System consistent with current Veterans Health Administration Patient Advocacy Program and facility policies and compliance is monitored.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-02493-122 | Summary | Report

Recommendations (12)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director conducts comprehensive reviews of all aspects of decision-making and care provided to Patient Red and Patient Blue, and takes action, as appropriate.

No. 2   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director considers conducting an institutional disclosure in Patient Red’s case, and takes action as appropriate.

No. 3   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director continues efforts to assess and improve inefficiencies, including on-call surgeon accountability issues, within the Orthopedic Surgery Department.

No. 4   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director takes appropriate action relative to the letter of expectation issued to the Chief of Orthopedic Surgery Department.

No. 5   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director addresses inter-departmental communication, collaboration, and problem-solving challenges as discussed in this report.

No. 6   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director follows up on consultative recommendations made by the anesthesia and operating room site visit team.

No. 7   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director evaluates the adequacy of Sterile Processing Services space and the loaner instrument policy, and takes action as appropriate.

No. 8   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director assesses the feasibility of implementing an electronic instrument tracking system within Sterile Processing Services, and takes actions as appropriate.

No. 9   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director revises the orthopedic surgery core privileges description to accurately reflect procedures performed at the Carl T. Hayden VA Medical Center.

No. 10   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director ensures appropriate data collection, analysis, and reporting for orthopedic providers’ ongoing professional practice evaluations.

No. 11   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director develops a physician assistant utilization policy as required by Veterans Health Administration.

No. 12   to Veterans Health Administration (VHA)

The Carl T. Hayden VA Medical Center Director updates physician assistant scopes of practice to fully reflect the activities and listing of surgical first assist responsibilities for individual orthopedic physician assistants.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 17-02186-114 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director defines goals, implements measures, and monitors outcomes to improve the flow of patients throughout the hospital, including the Emergency Department, inpatient medical and surgical units, mental health units, and the Community Living Center.

No. 2   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director conducts a review to evaluate the accuracy of data entered in Emergency Department Integration Software and takes action to ensure that the data collection tool may be used for operational improvement.

No. 3   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director ensures that patients admitted to a unit where there is no bed available receive the same level of care that is provided in the unit to which they are assigned.

No. 4   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director ensures that bed closures are reported to the Veterans Integrated Service Network as required by VA Loma Linda Healthcare System policy.

No. 5   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director evaluates the care of patients with sepsis in the Emergency Department, identifies opportunities for improvement, and takes actions to improve care.

No. 6   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director evaluates the response time of psychiatrists consulted for the care of mental health patients in the Emergency Department and takes action if required.

No. 7   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director conducts an evaluation of Patient C’s 2016 coordination of care, discharge planning, and transfer of care, including but not limited to, conferring with the Director of the Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky, and takes action as necessary.

No. 8   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System evaluates, develops, and implements processes for veterans who have anticipated or unexpected medical needs coordinated by their preferred medical facility and an alternate medical facility.

No. 9   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director evaluates and ensures that root cause analyses are completed in accordance with Veterans Health Administration directives.

No. 10   to Veterans Health Administration (VHA)

The VA Loma Linda Healthcare System Director reviews the care of the two fall patients with injuries discussed in this report, adheres to Veterans Health Administration policies, and takes action as appropriate.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-03159-74 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director ensures all psychologists are properly trained on coding.

No. 2   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director instructs the Chief of Psychology to review care provider coding accuracy in routine evaluations.

No. 3   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director makes certain the Chief of Health Information Management performs annual reviews of provider coding as specified in VHA policy.

No. 4   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director confirms that the Chief and Assistant Chief of Medical Administration Service, along with the Compliance Officer, provide adequate oversight of the Health Information Management provider coding reviews.

No. 5   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director ensures clinic hours are sufficiently scheduled to maximize direct patient care and to achieve targeted productivity.

No. 6   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director makes certain that all telehealth clinics follow VHA’s scheduling policies by using the approved electronic scheduling system and assigns properly trained telehealth schedulers.

No. 7   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director oversees proper disposal of the paper planner and secures patient information.

No. 8   to Veterans Health Administration (VHA)

The Central Texas Veterans Health Care System Director makes certain the Chief of Psychology determines, before authorizing overtime, whether the requested services could be performed during normal working hours.

Total Monetary Impact of All Recommendations

Open: $ 45,331.77
Closed: $ 0.00

| 17-05246-98 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, implements controls to ensure VA medical centers comply with policy to accurately annotate distribution of supply items.

No. 2   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, implements controls to ensure VA medical centers comply with policy to make supply logs available, include all required elements, and are used by VA medical center staff.

No. 3   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, strengthens procedures for VA medical centers to sufficiently conduct and document physical inventory results and retain documentation as required by VHA policy.

No. 4   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, strengthens controls at VA medical centers to ensure supplies are consistently secured.

No. 5   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, ensures VA medical centers affix barcode labels for all expendable supplies at the locations where the inventory items are stored.

No. 6   to Veterans Health Administration (VHA)

The Executive in Charge, Office of the Under Secretary for Health, strengthens procedures for the Veteran Integrated Service Network Quality Control Review process, ensuring a thorough review is conducted and action plans are developed and executed to address identified deficiencies at the VAMCs. In addition, update the Quality Control Review document regarding VA medical center security, access requirements, and improper distribution of supplies.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

| 18-01455-108 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director confirms that providers who perform patients’ clinical histories complete medication reconciliation to include non-VA medications.

No. 2   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director confirms that healthcare providers further evaluate patients when indicators of infection are present, including rising white blood cell counts, and that providers take action as appropriate.

No. 3   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director ensures that patient care teams verify that resources needed upon discharge, including family assistance, are available and meets patients’ needs.

No. 4   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director strengthens processes and documentation that is consistent with Veterans Health Administration Directive 1140.11 when elderly patients are transitioning in care.

No. 5   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director conducts a review of the interdisciplinary discharge planning team notes and patient discharge orders to identify and correct provider to patient communication deficiencies, and if deficiencies are noted, develop action plans to rectify the communication and mitigation issues identified.

No. 6   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director verifies that outpatient podiatry scheduling practices align with Veterans Health Administration and VA Eastern Colorado Health Care System podiatry scheduling policies and takes action as necessary.

No. 7   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director verifies that Wound Care Clinic practice aligns with VA Eastern Colorado Health Care System policy and takes action as necessary.

No. 8   to Veterans Health Administration (VHA)

The VA Eastern Colorado Health Care System Director ensures that a review is conducted of podiatry resident supervision and develop and implement corrective action plans with timelines and oversight of podiatry residency program as necessary.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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