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 VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program counselors provide treatment planning consistent with Title 42 of the Code of Federal Regulations Part 8, Substance Abuse and Mental Health Services Administration guidelines, and local policy requirements.

No. 2   to Veterans Health Administration (VHA)

We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program counselors provide counseling sessions consistent with Title 42 of the Code of Federal Regulations Part 8, Substance Abuse and Mental Health Services Administration guidelines, and local policy requirements.

No. 3   to Veterans Health Administration (VHA)

We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program leaders consider implementing clear policies regarding the management of cardiac risk that include annual electrocardiographic assessment consistent with Substance Abuse and Mental Health Services Administration guidelines.

No. 4   to Veterans Health Administration (VHA)

We recommended that the VA Maryland Health Care System Director ensure Opioid Agonist Treatment Program administrative policies assign regulatory compliance responsibilities consistent with Title 42 of the Code of Federal Regulations Part 8 and Substance Abuse and Mental Health Services Administration guidelines.

No. 5   to Veterans Health Administration (VHA)

We recommended that the VA Maryland Health Care System Director ensure that the Baltimore VA Medical Center Opioid Agonist Treatment Program Medical Director is present at the program a sufficient number of hours to ensure regulatory compliance consistent with Title 42 of the Code of Federal Regulations Part 8 and Substance Abuse and Mental Health Services Administration guidelines.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Audit of Purchase Card Use To Procure Prosthetics

9/29/2017 | 15-04929-351 | Summary | Report | 5 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended the Acting Under Secretary for Health require Prosthetic and Sensory Aids Service conduct periodic analyses of Veterans Health Administration prosthetic purchases to identify commonly used prosthetics that offer opportunities for VA’s Strategic Acquisition Center to leverage Veterans Health Administration’s purchasing power by pursuing Veterans Health Administration-wide or multi-Veterans Integrated Service Network contracts.

No. 2   to Veterans Health Administration (VHA)

We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office and Prosthetics and Sensory Aids Service to periodically monitor prosthetic procurements to ensure Veterans Integrated Service Networks and Network Contracting Offices identify and report prosthetics usage and cost data for use in developing Veterans Integrated Service Network contracts when Veterans Health Administration wide or multi-Veterans Integrated Service Network contracts are not possible.

No. 3   to Veterans Health Administration (VHA)

We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office to review fiscal years 2015 and 2016 prosthetic purchase card transactions above the micro-purchase limit and submit identified unauthorized commitments to Heads of Contracting Activities for ratification actions.

No. 4   to Veterans Health Administration (VHA)

We recommended the Acting Under Secretary for Health direct Heads of Contracting Activities to perform ratification actions for unauthorized commitments identified by the Procurement & Logistics Office review of fiscal years 2015 and 2016 prosthetic purchase card transactions above the micro-purchase limit and consider holding cardholders and their approving officials accountable for unauthorized commitments, as appropriate.

No. 5   to Veterans Health Administration (VHA)

We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office to develop a process for conducting periodic reviews to evaluate compliance with the requirements of VHA Directive 1081, VA Procurement Policy Memorandum 2016-02, and the Veterans Health Administration’s Memorandum, Implementation of the Implant Pre-authorization Process.

Total Monetary Impact of All Recommendations

Open: $ 3,120,699,904.00
Closed: $ 0.00

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the facility ensure the designated quality, safety, and value committee meets quarterly and is chaired or co-chaired by the Facility Director.

No. 2   to Veterans Health Administration (VHA)

We recommended that the facility revise the policy/by-laws to specify a frequency for clinical managers to review practitioners’ Ongoing Professional Practice Evaluation data every 6 months.

No. 3   to Veterans Health Administration (VHA)

We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data and that facility managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that the facility consistently evaluate actions for effectiveness in the Clinical Executive Committee and Performance Improvement Board and that facility managers monitor compliance.

No. 7   to Veterans Health Administration (VHA)

We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.

No. 8   to Veterans Health Administration (VHA)

We recommended that facility managers ensure horizontal surfaces, ventilation grills, and floors in patient care areas are clean and monitor compliance.

No. 9   to Veterans Health Administration (VHA)

We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.

No. 10   to Veterans Health Administration (VHA)

We recommended that facility managers ensure the standard operating procedure for the retrograde cholangiopancreatography endoscope is consistent with the manufacturer’s instructions for use.

No. 11   to Veterans Health Administration (VHA)

We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive competencies at orientation and annually for the types of reusable medical equipment they reprocess.

No. 12   to Veterans Health Administration (VHA)

We recommended that the facility revise the policy for anticoagulation management to include addressing no shows and patient noncompliance and minimizing loss to follow-up.

No. 13   to Veterans Health Administration (VHA)

We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.

No. 14   to Veterans Health Administration (VHA)

We recommended that clinical managers complete semiannual competency assessments for employees actively involved in the anticoagulant program and that facility managers monitor compliance.

No. 15   to Veterans Health Administration (VHA)

We recommended that the facility collect and report data on patient transfers out of the facility.

No. 16   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in transfer documentation and that facility managers monitor compliance.

No. 17   to Veterans Health Administration (VHA)

We recommended that facility managers ensure that for emergent transfers, provider transfer notes include patient stability for transfer and monitor compliance.

No. 18   to Veterans Health Administration (VHA)

We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.

No. 19   to Veterans Health Administration (VHA)

We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.

No. 20   to Veterans Health Administration (VHA)

We recommended that the facility report and trend the use of reversal agents in moderate sedation cases and process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.

No. 21   to Veterans Health Administration (VHA)

We recommended that the VA Police Officer, Patient Safety Manager and/or Risk Manager, and Patient Advocate consistently attend Disruptive Behavior Committee meetings.

No. 22   to Veterans Health Administration (VHA)

We recommended that the facility collect and analyze data from disruptive or violent behavior incidents.

No. 23   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.

No. 24   to Veterans Health Administration (VHA)

We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.

No. 25   to Veterans Health Administration (VHA)

We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.

No. 26   to Veterans Health Administration (VHA)

We recommended that all doors on the Domiciliary Care for Homeless Veterans Program unit other than the main point of entry be locked and alarmed.

No. 27   to Veterans Health Administration (VHA)

We recommended that the facility fully implement the nurse staffing methodology and conduct annual reassessments.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Review of Alleged Use of Wrong VA Funds To Purchase IT Equipment

9/29/2017 | 16-00753-338 | Summary | Report | 3 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended the Veterans Integrated Service Network 23 Director consult with VA’s Office of General Counsel and take necessary corrective actions to correct the funding error related to the purchase of WiFi and cable television services and ensure that appropriate funds are used for future information technology purchases in accordance with VA policy and VA’s Office of General Counsel guidance.

No. 2   to Veterans Health Administration (VHA)

We recommended the Veterans Integrated Service Network 23 Director work with the Chief Financial Officer to determine if an Antideficiency Act violation occurred and take action as deemed appropriate.

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

We recommended the Acting Assistant Secretary for Information and Technology update the 2016 IT/Non-IT Policy to address the dissemination of decisions and issues that may be systemic across VA.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

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

We recommended the Acting Assistant Secretary for Information and Technology implement appropriate controls to ensure that Class III software is not installed on VA networks without a formal technical review and authority to operate, and that training is provided to OIT Region 1 staff on the treatment of Class III software.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Inspection of the VA Regional Office Anchorage, Alaska

9/29/2017 | 17-02084-343 | Summary | Report | 5 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended the Anchorage VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.

No. 2   to Veterans Health Administration (VHA)

We recommended the Anchorage VA Regional Office Director strengthen oversight to ensure data input at the time of claims establishment is reviewed for accuracy.

No. 3   to Veterans Health Administration (VHA)

We recommended the Anchorage VA Regional Office Director implement a plan to monitor the effectiveness of training related to claims establishment procedures.

No. 4   to Veterans Health Administration (VHA)

We recommended the Anchorage VA Regional Office Director provide training for designated congressional liaison staff who process special controlled correspondence and monitor the effectiveness of the training.

No. 5   to Veterans Health Administration (VHA)

We recommended the Anchorage VA Regional Office Director implement a plan to ensure oversight is strengthened for special controlled correspondence.

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 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.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended the director of the STVHCS instruct PRMC to stop advising veterans that they may be liable for pre-authorized NVC.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Inspection of the VA Regional Office Winston-Salem, North Carolina

9/28/2017 | 17-00266-349 | Summary | Report | 7 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Benefits Administration (VBA)

We recommended the Winston-Salem Regional Office Director develop and implement a plan to monitor the effectiveness of training on higher-level special monthly compensation and ancillary benefits claims at the Winston-Salem VA Regional Office.

No. 2   to Veterans Benefits Administration (VBA)

We recommended the Winston-Salem VARO Director develop and implement a plan to ensure secondary reviewers accurately evaluate higher-level special monthly compensation and ancillary benefits claims at the Winston-Salem VA Regional Office.

No. 3   to Veterans Benefits Administration (VBA)

We recommended the North Atlantic District Director implement a plan to ensure oversight and prioritization of proposed rating reduction cases at the Winston-Salem VA Regional Office.

No. 4   to Veterans Benefits Administration (VBA)

We recommended that the Winston-Salem VARO Director ensure management provides a consistent quality review process addressing all elements required when establishing claims in the electronic record.

No. 5   to Veterans Benefits Administration (VBA)

We recommended the Winston-Salem VA Regional Office Director ensure VSC staff receive all mandatory annual training on claims establishment procedures.

No. 6   to Veterans Benefits Administration (VBA)

We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure the Public Contact Coach and Congressional Liaisons adhere to Veterans Benefits Administration policy when processing special controlled correspondence.

No. 7   to Veterans Benefits Administration (VBA)

We recommended the Winston-Salem VA Regional Office Director provide standardized training to Congressional Liaisons on processing special controlled correspondence.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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