OIG Reports

No. 1   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of the patient and third-party contacts, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

No. 2   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director expedites the alignment of the Medora documentation template with the VA and Department of Defense Clinical Practice Guideline and Veterans Crisis Line guidelines for suicide risk assessment classification levels.

No. 3   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director ensures and strengthens the quality management oversight of staff who provide crisis management services, including overtime coverage.

No. 4   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director confirms the retention of crisis management text conversations and establishes supervisory oversight protocols.

No. 5   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director ensures issue briefs accurately reflect the action plan.

No. 6   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director identifies criteria for immediate internal reviews of customers’ deaths by suicide and accidental overdose to identify crisis management and administrative performance improvement actions.

No. 7   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a full review of the patient’s text contact, determines whether an institutional disclosure is warranted, and takes action as indicated.

No. 8   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director monitors compliance with the submission and oversight of notification of a customer’s death, including timely submission of a suicide prevention coordinator consult.

No. 9   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a review of the interactions between the Director, Quality and Training, and staff in preparation and during the Office of Inspector General healthcare inspection, educates staff on the importance of fully cooperating, responding in an open and transparent manner, and avoiding any appearance of coordination between employees, and take actions as warranted.

No. 10   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director clarifies and strengthens procedures for complaint submission, provides staff training, ensures consistency with the Veterans Health Administration directive, and monitors compliance.

No. 11   to Veterans Health Administration (VHA)

The South Texas Veterans Health Care System Director ensures that processes are established for timely death notification entry in patients’ electronic health records.

No. 12   to Veterans Health Administration (VHA)

The South Texas Veterans Health Care System Director ensures that staff adheres to the January 2022 standard operating procedures for administrative and clinical actions following a patient’s or employee’s death by suicide.

No. 13   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director strengthens processes to ensure discontinuation of caring letters in a timely manner following notification of a patient’s death.

No. 14   to Veterans Health Administration (VHA)

The South Texas Veterans Health Care System Director makes certain that the Suicide Prevention Program ensures full implementation of the Behavioral Health Autopsy Program as required by the Veterans Health Administration.

No. 1   to Veterans Health Administration (VHA)

The Fayetteville VA Coastal Health Care System Director ensures time frames for interpretation of echocardiograms are formalized and monitors for compliance.

No. 2   to Veterans Health Administration (VHA)

The Fayetteville VA Coastal Health Care System Director reviews Facility Policy 11-40, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge dated January 2022 and SOP 11-10, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge Standard Operating Procedure and confirms that policy and procedures for an admission requiring continuous renal replacement therapy align with equipment and trained staff available at the facility.

No. 3   to Veterans Health Administration (VHA)

The Fayetteville VA Coastal Health Care System Director ensures facility staff are educated on the community living center delineation of after-hour coverage and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Fayetteville VA Coastal Health Care System Director confirms hospitalists are educated on reporting patient safety issues and monitors patient safety reporting compliance.

No. 5   to Veterans Health Administration (VHA)

The VA Mid-Atlantic Health Care Network Director reviews privileging processes and policies to ensure that facility leaders follow privileging processes and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Fayetteville VA Coastal Health Care System Director requires the chief of medicine to use focused professional practice evaluations and ongoing professional practice evaluations to evaluate provider performance per policy and monitors compliance.

No. 1   to Veterans Health Administration (VHA)

The Richard L Roudebush VA Medical Center Director ensures the Chief of Staff, chief of medicine, and chief of cardiology, in consultation with the National Cardiology Program Office, reevaluate the Cardiology Department and establish and implement a long-term service plan that includes cardiology services and cardiologist and specialty cardiologist staffing levels.

No. 2   to Veterans Health Administration (VHA)

The Richard L Roudebush VA Medical Center Director provides the chief of cardiology with the dedicated resources needed to develop, implement, and sustain Cardiology Department changes.

No. 3   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director provides oversight of the Richard L Roudebush VA Medical Center Director’s development and implementation of a long-term Cardiology Department plan, monitors the department’s progress, and ensures changes are sustained.

No. 4   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director ensures the Richard L Roudebush VA Medical Center Director continues to strengthen and maintain the Cardiology Department’s relationship with the university affiliate, including residency and fellow cardiology programs and joint efforts to recruit cardiologists.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by allowing a facility to conduct lung cancer screening while developing all mandated elements.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health considers mandating eligible patients be offered lung cancer screening consistent with other required cancer screening in the Veterans Health Administration.

No. 1   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director establishes a process to optimize communication between the Surgery Service and the Spinal Cord Injury Service when providing care to spinal cord injury patients.

No. 1   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director evaluates processes for mental health consult scheduling, including community care referrals, and ensures patients are offered timely appointments, per Veterans Health Administration policies.

No. 2   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director confirms outpatient Mental Health staff receive education about Veterans Health Administration and facility policies related to mental health consult processes, including timeliness and community care consults.

No. 3   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director evaluates the design, staffing, and implementation of the Behavioral Health Interdisciplinary Program to ensure the program supports timely access to mental health care and takes action as appropriate.

No. 4   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director confers with Mental Health leaders to identify, track, and mitigate barriers to staff retention and takes appropriate action.

No. 5   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director ensures Mental Health leaders review current communication practices within Mental Health operations, in accordance with Veterans Health Administration High Reliability Organization values and principles and considers the use of VHA resources, such as the National Center for Organization Development.

No. 6   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director ensures Mental Health leaders educate Mental Health clinic staff on the role of the suicide prevention team in patient care.

No. 7   to Veterans Health Administration (VHA)

The Charles George VA Medical Center Director reviews and evaluates processes for monitoring and managing Veterans Health Administration-required follow-up care for patients with high risk for suicide patient record flags, including scheduling and tracking of required follow-up appointments, and monitoring compliance.

No. 1   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures communication with patients, families, and staff throughout emergency operations according to the Veterans Health Administration’s Emergency Management Program Guidebook.

No. 2   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director confirms that medical, nursing, and respiratory therapy staff have the equipment, education, and training to prepare for emergency oxygen procedures.

No. 3   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures completion of pre-construction risk assessments.

No. 4   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures patient safety staff participate in facility Construction Safety Committee meetings and activities.

No. 5   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director evaluates the need for increased oversight of contracted construction companies during high-risk or potential high-risk situations such as construction around underground utilities.

No. 6   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures annual drills and training to address utility emergencies are completed.

No. 7   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director confirms that joint patient safety reports are entered for adverse events and close calls and root cause analyses are chartered for high-risk events or potential high-risk events not related to falls, medications, and missing patients.

No. 8   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures clinical staff document each event of a patient’s care into the health record.

No. 9   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures that the patient’s episodes of care are reviewed to determine whether a clinical disclosure is needed in accordance with Veterans Health Administration requirements and takes action accordingly.

No. 10   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director ensures that staff who are designated as a fact finder for a fact-finding investigation receive the needed training and do not have a conflict of interest.

No. 11   to Veterans Health Administration (VHA)

The West Haven VA Medical Center Director determines whether administrative action should be taken with respect to the conduct and performance of the chief of respiratory care.

No. 12   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director reviews the content, accuracy, and intent of the Situation, Background, Assessment, Recommendation document and takes administrative action as warranted.

No. 1   to Veterans Health Administration (VHA)

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director evaluates and ensures all Veterans Integrated Service Network 10 facilities comply with Veterans Health Administration requirements regarding resident supervision, specifically related to post-graduate year one on-site direct supervision.

No. 2   to Veterans Health Administration (VHA)

The John D. Dingell VA Medical Center Director reviews the March 2023 National Surgery Office program review as referenced in the Office of the Medical Inspector report and ensures a comprehensive and sustainable response to the recommendations noted in the National Surgery Office memorandum.

No. 3   to Veterans Health Administration (VHA)

The John D. Dingell VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for National Practitioner Data Bank and State Licensing Board reporting for healthcare providers that meet reporting criteria.

No. 4   to Veterans Health Administration (VHA)

The John D. Dingell VA Medical Center Director ensures the chief of surgery facilitates and provides oversight of morbidity and mortality conferences.

No. 5   to Veterans Health Administration (VHA)

The John D. Dingell VA Medical Center Director ensures that initial level 3 peer review results of Peer Review Committee members’ cases are reassessed by another neutral VA facility Peer Review Committee for final level determination.

No. 6   to Veterans Health Administration (VHA)

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network academic affiliations officer maintains awareness of and performs assigned roles and responsibilities per Veterans Health Administration requirements.

No. 7   to Veterans Health Administration (VHA)

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network surgical workgroup reviews applicable Veterans Health Administration policies, and documents discussion and action plans to reflect facilities’ compliance with Veterans Health Administration policy and surgical complexity level.

No. 8   to Veterans Health Administration (VHA)

The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director provides continued oversight and structured support to executive and service line leaders during key leader transitions, and monitors actions taken to ensure completion of action plans.

No. 9   to Veterans Health Administration (VHA)

The John D. Dingell VA Medical Center Director reviews organizational communication channels and ensures consistency with Veterans Health Administration High Reliability Organization goals and considers the use of Veterans Health Administration resources such as the Veterans Health Administration National Center for Organization Development.

No. 1   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director conducts a fact-finding investigation asnecessary to determine whether the chief of the Emergency Department’s conduct wasinconsistent with VA policy and federal regulations and takes action as appropriate.

No. 2   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director establishes a standardized process for theadministration of the Columbia-Suicide Severity Rating Scale by Emergency Department staff topatients to maintain the integrity of the suicide risk screen.

No. 3   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director establishes a formal policy outliningexpectations for the monitoring of patients by Emergency Department nursing staff after triage.

No. 4   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director ensures root cause analyses and administrativeinvestigations are conducted efficiently and effectively if chartered for the same event as perVeterans Health Administration policy.

No. 5   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director ensures that institutional disclosures arecompleted within the time frame required by the Veterans Health Administration.

No. 6   to Veterans Health Administration (VHA)

The VA St. Louis Health Care System Director ensures compliance with the Veterans HealthAdministration requirement for reporting healthcare professionals to the appropriate statelicensing board when indicated.

No. 1   to Veterans Health Administration (VHA)

The VA Southern Nevada Healthcare System Director reviews processes in place to ensure proper response to future medical emergencies in outpatient clinics to include staff training, emergency notification systems, and emergency documentation processes.

No. 2   to Veterans Health Administration (VHA)

The VA Southern Nevada Healthcare System Director reviews the process for and compliance with documentation of cardiopulmonary resuscitation in outpatient clinic settings, and takes action as indicated.

No. 3   to Veterans Health Administration (VHA)

The VA Southern Nevada Healthcare System Director works with outpatient clinic leaders to ensure that all deficiencies identified in the after-action plan are completed and that compliance is monitored.

No. 4   to Veterans Health Administration (VHA)

The VA Southern Nevada Healthcare System Director consults with Office of General Counsel’s Regional Counsel to review the incident and determine if an institutional disclosure is warranted and takes action accordingly.

No. 5   to Veterans Health Administration (VHA)

The VA Southern Nevada Healthcare System Director completes an evaluation of staffs’ understanding of advance care planning, advance directives, and life-sustaining treatment decision processes, and takes action to address identified gaps.