OIG Reports

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health directs the Office of Primary Care and Office of Mental Health and Suicide Prevention to identify barriers to provider documentation of opioid use disorder in progress notes and implement solutions addressing these barriers.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention determine impediments to maintaining accurate identification of opioid use disorder in electronic health record problem lists and implement policy and training to support accurate use of problem lists.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health confirms the Office of Primary Care and Office of Mental Health and Suicide Prevention evaluate barriers affecting provider access and use of Department of Defense treatment records in Joint Longitudinal Viewer and implement solutions.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention improve continuity of care by confirming providers are educated on the navigation and retrieval of Department of Defense treatment records in Joint Longitudinal Viewer.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health requires the Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer to evaluate and update processes for identification of veterans with a history of opioid use disorder for the provision of opioid overdose risk mitigation strategies.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates provider knowledge and utilization of VA Video Connect technology, including resources such as the Digital Divide Consult, Connected Devices Support Program, and VVC Now and takes action as indicated.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates availability of clinical and administrative support to providers initiating and completing VA Video Connect encounters and clarifies expectations and requirements to ensure access to virtual care emulates in-person encounters.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures education of providers and support staff regarding VA Video Connect scheduling processes.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures the Office of Mental Health and Suicide Prevention develops, implements, and monitors action plans to meet Intensive Community Mental Health Recovery visit frequency requirements, to include program resource needs and the ongoing role for virtual care.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health requires the Office of Mental Health and Suicide Prevention to develop a process for Intensive Community Mental Health Recovery programs to ensure veterans receiving low-intensity services do not represent greater than 20 percent of caseloads and to distinguish between veterans receiving high- and low-intensity services for accurate and effective program oversight.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health identifies barriers and ensures healthcare systems develop, implement, and maintain contingency plans specific to Intensive Community Mental Health Recovery programs regarding veteran access to medications during emergencies, including long-acting injectable antipsychotic medications.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures compliance with suicide risk and lethal means safety training requirements.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the efficacy of the May 2022 Veterans Integrated Service Network and Office of Mental Health and Suicide Prevention oversight structure for suicide risk training and considers inclusion of an oversight structure for lethal means safety training compliance.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the adequacy of the one-time lethal means safety training requirement and takes action as appropriate.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures clinician completion of comprehensive suicide risk evaluations including the discussion and documentation of firearms access and safe storage as required, and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures clinician completion of safety plans including the discussion and documentation of firearms access and safe storage, as applicable, and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates staff’s perceived barriers to completion of the suicide risk identification strategy and takes action as appropriate.

No. 7   to Veterans Health Administration (VHA)

The Under Secretary for Health considers initiatives to evaluate and address educational and cultural barriers to conducting and documenting patient discussions related to firearms access and safe storage practices.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.

No. 5   to Veterans Health Administration (VHA)

The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.

No. 6   to Veterans Health Administration (VHA)

The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.

No. 7   to Veterans Health Administration (VHA)

The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures medical facility directors make certain that a written policy is in place and implemented for the safe, appropriate, orderly, and timely transfer of patients.

No. 2   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures chiefs of staff and associate directors of patient care services monitor and evaluate all transfers as part of Veterans Health Administration’s Quality Management Program.

No. 3   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff ensure that transferring providers send patients’ active medication lists and copies of advance directives to receiving facilities during inter-facility transfers.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain chiefs of staff and associate directors of patient care services ensure nurse-to-nurse communication occurs during the inter-facility transfer process.

No. 1   to Veterans Health Administration (VHA)

The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures healthcare providers inform patients and/or caregivers when a medication is not FDA-approved; provide the option to refuse the medication; and advise them of the known risks, benefits, and alternatives prior to administration.