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)

The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data at least every 6 months and monitors managers’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures that facility managers maintain a safe and clean environment in all patient care areas and monitors the managers’ compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by the medical staff and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures social workers and registered nurses conduct alternating, cyclical clinical visits with the required frequency and monitors their compliance.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff ensures acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director ensures a safe respiratory environment for patients and employees in the Community Living Center units and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA); Office of Information and Technology (OIT)

The OIG recommended the executive in charge for the Office of the Under Secretary for Health, in conjunction with the executive in charge for the Office of Information and Technology, ensure that all guest internet access networks, external air gapped networks, and industrial control systems are appropriately segregated from VA networks and meet the department’s information security requirements.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Facility Director requires the Quality, Safety, and Value Council to document meeting minutes that include evidence of the review and analysis of aggregated data, identification of opportunities for improvement, implementation of corrective actions, and evaluation of effectiveness of the actions and monitors the Quality, Safety, and Value Council’s compliance.

No. 2   to Veterans Health Administration (VHA)

The Associate Director for Patient Care Services ensures that for patients transferred out of the facility, sending nurses document transfer assessments/notes and monitors the nurses’ compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information and monitors providers’ compliance.

No. 4   to Veterans Health Administration (VHA)

The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.

No. 5   to Veterans Health Administration (VHA)

The Associate Director ensures access to sterile supplies at the Gallipolis community based outpatient clinic is restricted and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Associate Director ensures medical (biohazardous) waste stored for pick-up at the Gallipolis community based outpatient clinic is secured and monitors compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Community Nursing Home Oversight Committee includes a representative from acquisitions.

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 Veterans Integrated Service Network Director ensure that the System Director evaluates the care of the subject patient (Patient 1) and consults with the Office of General Counsel for disclosure to the patient, if appropriate.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that the System Director consults with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action(s), if any, for Primary Care Provider X and Primary Care Provider X’s supervisors.

No. 3   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that providers notify patients of test values and follow up on clinical laboratory results as required.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that providers accurately document patients’ assessment, diagnosis, and treatment information into the electronic health record.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that consults for VHA and non-VA care are entered and completed within time frames set by Veterans Health Administration.

No. 6   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that employees receive training appropriate for the assigned Workplace Behavioral Risk Assessment risk level.

No. 7   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that Clinic employees are trained in emergency management procedures.

No. 8   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that emergency procedures and contact information are posted and readily available to Clinic employees.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure Facility Directors establish Employee Threat Assessment Teams.

No. 2   to Veterans Health Administration (VHA)

OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require attendance by VA Police Officers, Patient Safety and/or Risk Management Officials, and Patient Advocates at Disruptive Behavior Committee/Board meetings and monitor compliance.

No. 3   to Veterans Health Administration (VHA)

OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when Chiefs of Staff (or designees) issue Orders for Behavioral Restriction, they document that they informed patients that the Orders were issued and of the right to appeal the decisions and that facility senior managers monitor compliance.

No. 4   to Veterans Health Administration (VHA)

OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require that within 90 days of hire, all employees complete Level I Prevention and Management of Disruptive Behavior training and additional training levels based on the type and severity of risk for exposure to disruptive and unsafe behaviors and monitor compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.

No. 2   to Veterans Health Administration (VHA)

The Facility Director ensures the Patient Safety Manager consistently provides feedback to employees or departments who submit close call and adverse event reports that result in a root cause analysis and monitors the manager’s compliance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff ensures anticoagulation program managers establish a defined process for anticoagulation-related calls outside normal business hours and monitors compliance with the process.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Pharmacy and Therapeutics Committee reviews anticoagulation data quarterly and monitors the committee’s compliance.

No. 5   to Veterans Health Administration (VHA)

The Facility Director ensures inter-facility patient transfer data are reported to a quality oversight committee and monitors compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include in transfer documentation patient or surrogate informed consent and monitors the clinicians’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently document sending or communicating pertinent patient information to the receiving facility and monitors the clinicians’ compliance.

No. 8   to Veterans Health Administration (VHA)

The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.

No. 9   to Veterans Health Administration (VHA)

The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors employees’ and team members’ compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The OIG recommended the Acting Assistant Secretary for the Office of Information and Technology ensure the new directive reflects updates so that new and emerging advances in information technology are included.

No. 2   to Veterans Health Administration (VHA)

The OIG recommended the Acting Under Secretary for Health ensure VHA’s Chief Financial Officer, in consultation with VA’s Chief Financial Officer and Office of General Counsel, determine which medical care appropriation VHA should use for mobile health application development and notify VHA staff offices accordingly.

No. 3   to Veterans Health Administration (VHA)

The OIG recommended the Acting Assistant Secretary for the Office of Management issue a memorandum reiterating the importance of complying with the United States Code, Federal Regulations, and VA’s current policies on the proper use of appropriations.

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 strengthening of procedures for timely processing of Release of Information requests.

No. 2   to Veterans Health Administration (VHA)

We recommended that the System Director strengthen the process to adequately capture and trend complaints related to Release of Information requests in accordance with Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

We recommended that the System Director ensure an evaluation of the personnel issues negatively impacting staff retention and hiring in the Release of Information section and take appropriate action.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure accurate monitoring of Release of Information staff productivity.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director ensure accurate and effective trackingand monitoring processes of Release of Information requests.

No. 6   to Veterans Health Administration (VHA)

We recommended that the System Director ensure consultation with the Office ofHuman Resources and the Office of General Counsel to determine the appropriateadministrative action, if any, for managers’ performance related to implementation ofcorrective action plans in response to privacy violations.

No. 7   to Veterans Health Administration (VHA)

We recommended that the System Director ensure Release of Information standardoperating procedures are established in accordance with VHA policy and implemented consistently.

No. 8   to Veterans Health Administration (VHA)

We recommended that the System Director strengthen working relationships andcommunication processes within the facility Release of Information section andamongst staff and Business Office Service managers.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

The Facility Director requires the Patient Safety Manager to ensure completion of the required minimum of eight root cause analyses each fiscal year.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff requires the Pharmacy and Therapeutics Committee to review all quality assurance data for the anticoagulation management program and monitors the committee’s compliance.

No. 3   to Veterans Health Administration (VHA)

The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.

No. 4   to Veterans Benefits Administration (VBA)

The Chief of Staff ensures management-level representatives from all required disciplines consistently attend Community Nursing Home Oversight Committee meetings and monitors their compliance.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff ensures social workers conduct cyclical clinical visits with the required frequency and monitors the social workers’ compliance.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff ensures Mental Health Residential Rehabilitation Treatment Program employees perform and document weekly contraband inspections and monitors employees’ compliance.

No. 7   to Veterans Health Administration (VHA)

The Associate Director ensures that closed circuit television surveillance systems are repaired or replaced for all required areas in the Mental Health Residential Rehabilitation Treatment Program units.

No. 8   to Veterans Health Administration (VHA)

The Chief of Staff ensures the Mental Health Residential Rehabilitation Treatment Program units have signage alerting patients and visitors of closed circuit television recording.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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2/25/2018 9:35:29 PM


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