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

OIG Reports

| 22-01341-43 | Summary | Report

Recommendations (7)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.

No. 2   to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.

No. 3   to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.

No. 4   to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.

No. 5   to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.

No. 6   to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director reviews the patient’s acute care, including actions to address medical recommendations, and takes actions as indicated.

No. 7   to Veterans Health Administration (VHA)

The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.

| 22-00707-44 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The North Las Vegas Medical Center Director ensures, through training and observation, that the primary care provider is competent completing and documenting primary care VA Video Connect visits.

No. 2   to Veterans Health Administration (VHA)

The North Las Vegas Medical Center Director considers taking administrative action in relation to the primary care provider, as appropriate.

No. 3   to Veterans Health Administration (VHA)

The North Las Vegas Medical Center Director considers the need to initiate reporting the primary care provider to the state licensing board and takes action as necessary.

No. 4   to Veterans Health Administration (VHA)

The North Las Vegas Medical Center Director ensures a review is conducted of the primary care provider’s electronic health record documentation in order to determine if blood pressure entries other than 120/80 are false and takes action as necessary.

No. 5   to Veterans Health Administration (VHA)

The North Las Vegas Medical Center Director ensures that any identified false blood pressures are amended in the electronic health record in accordance with Veterans Health Administration policy.

| 22-01668-45 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director ensures that Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints.

No. 2   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director evaluates the process of clinical consultation for Emergency Department physician assistants and takes action as necessary.

No. 3   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director evaluates the status of action plans set forth in the facility’s review of the patient care from the second visit and institutional disclosure, monitoring the implementation and efficacy of action items to closure.

No. 4   to Veterans Health Administration (VHA)

The VA Maryland Health Care System Director evaluates and strengthens the process to ensure that problem lists reflect current and active diagnoses, and takes action as necessary.

| 21-03734-32 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director reviews the supervision provided to the psychiatry trainee regarding the patient’s treatment, documentation, and document control, to include electronic health records and video recordings, and determines if standards were met, and takes action as indicated.

No. 2   to Veterans Health Administration (VHA)

The Veterans Integrated Service Network Director reviews treatment protocols for video recorded therapy, specifically the management of patient access to recordings, and takes action as indicated.

No. 3   to Veterans Health Administration (VHA)

The Greater Los Angeles Healthcare System Director reviews the facility leader and staff responses, including those of the supervisor and patient advocate, to ensure the patient’s concerns were adequately addressed, and takes action as indicated.

No. 4   to Veterans Health Administration (VHA)

The Under Secretary for Health conducts a review to assess the possible scope of current and former VA psychiatry residents being in possession of patients’ personal health information, to include video recorded treatment sessions and consent forms, and consults with the appropriate organizational leaders such as the Office of General Counsel on the required disposition of the recordings and forms, and takes action as needed.

No. 5   to Veterans Health Administration (VHA)

The Greater Los Angeles Healthcare System Director ensures records control schedules, including one for video recordings, are completed for the Mental Health Department as required by Veterans Health Administration policy.

No. 6   to Veterans Health Administration (VHA)

The Greater Los Angeles Healthcare System Director reviews processes related to the utilization of video recordings, in consultation with appropriate staff, to ensure compliance with Veterans Health Administration requirements.

| 21-02511-28 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors complete suicide risk assessments and assign risk levels based on client risk factors, reevaluate levels when risk factors change, and monitors staff’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors consistently mitigate clients’ risk for suicide, as appropriate, by developing personalized safety plans, seeking clinical consultation, increasing client contact efforts, and completing crisis reports, and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Midwest District 3 Director ensures that when clients are transferred from one counselor to another, relevant clinical information is communicated, applicable safety measures are in place, services are not disrupted, and when possible, a joint session with the outgoing and incoming counselor is held with the client.

No. 4   to Veterans Health Administration (VHA)

The Midwest District 3 Director reviews Client 1’s post-hospitalization care and the care coordination from the intern to a new counselor and determines if an adverse event disclosure is warranted.

No. 5   to Veterans Health Administration (VHA)

The Chief Readjustment Counseling Officer reviews VHA Directive 1004.08, Disclosure of Adverse Events to Patients, and develops a clear policy or protocol outlining the pathway for Readjustment Counseling Service leaders to comply with adverse event reporting, and monitors reporting compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief Readjustment Counseling Officer ensures that prior to Readjustment Counseling Service accepting new interns, Readjustment Counseling Service leaders develop and implement a formalized intern orientation and training curriculum, as well as a clear supervisory oversight and safety protocol.

No. 7   to Veterans Health Administration (VHA)

The Midwest District 3 Director evaluates whether the Vet Center Director’s clinical practice warrants reporting to the state licensing board and takes action, as indicated.

No. 8   to Veterans Health Administration (VHA)

The Chief Readjustment Counseling Officer reviews VHA Directive 1100.18, Reporting and Responding to State Licensing Boards, and develops a clear policy or protocol outlining the pathway for Readjustment Counseling Service leaders to evaluate substandard care or ethical violations by licensed counselors, and when appropriate, reports concerns to state licensing boards.

| 21-03231-38 | Summary | Report

Recommendations (23)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The District Director determines reasons annual in-service training was not provided for vet center directors, veteran outreach program specialists, and office managers and ensures training is offered for all positions as required.

No. 2   to Veterans Health Administration (VHA)

The District Director determines reasons clinical quality review remediation plans were not completed for the Grand Rapids and South Bend Vet Centers, ensures completion, and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The District Director determines reasons clinical quality review remediation plans at the four selected vet centers did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Cleveland, Columbus, and Toledo Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Cleveland, Columbus, and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance

No. 6   to Veterans Health Administration (VHA)

The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution for the Columbus and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The District Director determines reasons why morbidity and mortality reviews for serious suicide attempts were not completed, ensures completion, and monitors compliance.

No. 8   to Veterans Health Administration (VHA)

The Readjustment Counseling Service Chief Officer defines “serious suicide attempt” and establishes criteria for when a morbidity and mortality review is required as well as a standardized process for completing the review.

No. 9   to Veterans Health Administration (VHA)

The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.

No. 10   to Veterans Health Administration (VHA)

The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.

No. 11   to Veterans Health Administration (VHA)

The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.

No. 12   to Veterans Health Administration (VHA)

The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.

No. 13   to Veterans Health Administration (VHA)

The District Director ensures clinical staff make timely notification to the suicide prevention coordinator at the support VA medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.

No. 14   to Veterans Health Administration (VHA)

The District Director ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required, and monitors compliance across all zone vet centers.

No. 15   to Veterans Health Administration (VHA)

The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider to include the suicide prevention coordinator following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.

No. 16   to Veterans Health Administration (VHA)

The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Columbus, South Bend, and Toledo Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.

No. 17   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk-suicide flag or clients with an increased predictive risk for suicide at the Columbus, South Bend, and Toledo Vet Centers, takes action to ensure requirements are met, and monitors compliance.

No. 18   to Veterans Health Administration (VHA)

The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures vet center directors implement processes, and monitors compliance.

No. 19   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures staff supervision occurs as required, and monitors compliance.

No. 20   to Veterans Health Administration (VHA)

The District Director verifies and determines reasons for noncompliance with monthly RCSNet chart audits at the Cleveland, Columbus, South Bend, and Toledo Vet Centers; ensures chart audits are completed as required; and monitors compliance.

No. 21   to Veterans Health Administration (VHA)

The District Director determines reasons staff at the Cleveland, Columbus, South Bend, and Toledo Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.

No. 22   to Veterans Health Administration (VHA)

The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Toledo Vet Center and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards.

No. 23   to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance with maintaining a current and comprehensive emergency and crisis plan at the Cleveland, South Bend, and Toledo Vet Centers and ensures all emergency and crisis plans are comprehensive and updated as required.

| 22-01836-12 | Summary | Report

Recommendations (9)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Information and Technology (OIT)

Implement a vulnerability management program that ensures system changes within established deadlines.

No. 2   to Office of Information and Technology (OIT)

Develop and approve a system security plan and an authorization to operate for the special-purpose system.

No. 3   to Office of Information and Technology (OIT)

Include language for contractors to follow federal and VA information technology security requirements in contracts that have an information technology component.

No. 4   to Office of Information and Technology (OIT)

Verify that access control lists have been applied to network segments that contain medical systems.

No. 5   to Office of Information and Technology (OIT)

Develop and implement a process to retain database logs for a period consistent with VA’s record retention policy.

No. 6   to Veterans Health Administration (VHA)

Develop and implement controls to remove an individual’s access rights to computer rooms when access is no longer necessary.

No. 7   to Veterans Health Administration (VHA)

Implement a process to regularly review applicable reports to ensure that only authorized individuals have computer room access and update the system access authorization memo to include only those individuals necessary to perform job functions.

No. 8   to Veterans Health Administration (VHA)

Validate that appropriate physical and environmental security measures are implemented and functioning as intended.

No. 9   to Veterans Health Administration (VHA)

Inventory and verify that records containing personally identifiable information and personal health information are adequately secured.

| 22-01854-13 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Information and Technology (OIT)

Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.

No. 2   to Office of Information and Technology (OIT)

Ensure vulnerabilities are remediated within established time frames.

No. 3   to Office of Information and Technology (OIT)

Ensure all databases at the Tuscaloosa VA Medical Center are part of the periodic database scan process.

No. 4   to Office of Information and Technology (OIT)

Implement improved mechanisms to ensure system stewards are updating plans of actions and milestones for all known risks and weaknesses, including those identified during security control assessments.

No. 5   to Office of Information and Technology (OIT)

Ensure network segmentation controls are applied to all network segments with medical devices and special-purpose systems.

No. 6   to Office of Information and Technology (OIT)

Implement capabilities for generating database audit logs and forwarding audit events for review, analysis, and reporting.

No. 7   to Veterans Health Administration (VHA)

Ensure communication rooms with infrastructure equipment have adequate environmental controls.

No. 8   to Veterans Health Administration (VHA)

Install uninterruptible power supplies in the communication rooms supporting infrastructure equipment.

| 22-00029-40 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director reviews credentialing and privileging practices to identify and address staff training deficiencies in verifying documentation required for credentialing and privileging of new providers.

No. 2   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director ensures that newly trained interventional cardiologists are mentored by experienced physicians until it is determined that their skills, judgement, and outcomes are deemed safe to be placed on independent call for high-risk procedures as required by facility standard operating procedure.

No. 3   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director ensures that staff conduct and document focused professional practice evaluations as required by Veterans Health Administration.

No. 4   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director ensures timely completion of factfinding reviews to promptly identify and address system vulnerabilities.

No. 5   to Veterans Health Administration (VHA)

The Richard L. Roudebush VA Medical Center Director assesses the volume of percutaneous coronary intervention for ST-elevation myocardial infarction procedures performed in the cardiac catheterization laboratory and determines a path forward to comply with facility standard operating procedures.

| 21-01823-31 | Summary | Report

Recommendations (2)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The VISN 7 Director ensures VISN leaders, providers, and program staff monitor the quality of contracted clinical services for patients receiving non-VA home dialysis services.

No. 2   to Veterans Health Administration (VHA)

The VISN 7 Director ensures that ordering providers communicate normal mammography results to patients within 14 calendar days.

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