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

OIG Reports

| 21-03232-37 | Summary | Report

Recommendations (18)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 did not include documentation of deficiency resolution and the time frame for resolution for the Fargo, Omaha, and Sioux Falls Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

No. 3   to Veterans Health Administration (VHA)

The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers, takes indicated actions to ensure completion, and monitors compliance.

No. 4   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. 5   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. 6   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. 7   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. 8   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. 9   to Veterans Health Administration (VHA)

The District Director verifies 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. 10   to Veterans Health Administration (VHA)

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

No. 11   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. 12   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 at the Columbia and Fargo Vet Centers, takes action to ensure requirements are met, and monitors compliance.

No. 13   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with processes for completing and tracking four hours of external clinical consultation per month at the Columbia, Fargo and Omaha Vet Centers, ensures vet center directors implement processes, and monitors compliance.

No. 14   to Veterans Health Administration (VHA)

The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers, ensures staff supervision occurs as required, and monitors compliance.

No. 15   to Veterans Health Administration (VHA)

The District Director verifies and determines reasons for noncompliance with monthly RCSNet chart audits at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers, ensures chart audits are completed as required, and monitors compliance.

No. 16   to Veterans Health Administration (VHA)

The District Director determines reasons staff at the Columbia, Fargo, Omaha, and Sioux Falls Vet Centers did not complete required trainings, ensures all mandatory trainings are complete, and monitors compliance.

No. 17   to Veterans Health Administration (VHA)

The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Columbia, Fargo, and Omaha Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.

No. 18   to Veterans Health Administration (VHA)

The District Director reviews reasons for noncompliance of a missing date on the emergency and crisis plan at the Fargo Vet Center and ensures compliance.

| 22-00043-39 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis or includes the patient safety event in an aggregate review for all events assigned an actual or potential safety assessment code score of three.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff determines the reasons for noncompliance and ensures that practitioners with similar training and privileges complete Focused Professional Practice Evaluations of licensed independent practitioners.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Clinical Executive Board reviews and recommends licensed independent practitioners for reprivileging based on individual practitioners’ Ongoing Professional Practice Evaluations and documents its decisions in meeting minutes.

| 21-03308-24 | Summary | Report

Recommendations (10)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs’ determinations to continue current privileges are based on Ongoing Professional Practice Evaluation activities.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Committee’s decision to recommend continuation of privileges is based on Ongoing Professional Practice Evaluation results.

No. 6   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures staff have a current local intranasal naloxone policy.

No. 7   to Veterans Health Administration (VHA)

The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain managers adhere to commercial product expiration dates in the community living center.

No. 8   to Veterans Health Administration (VHA)

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures managers keep furnishings safe and in good repair.

No. 9   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director of Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff develop abatement plans to minimize risks for suicide and suicide attempts in acute inpatient mental health units.

No. 10   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete 100 percent of required universal and setting-specific screenings and Comprehensive Suicide Risk Evaluations.

| 21-03063-04 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

Update the process for developing, approving, and issuing guidance for accommodating veterans with visual impairments to include steps for consulting with the Office of General Counsel; Office of Resolution Management, Diversity and Inclusion; and the Department of Justice Civil Rights Division.

No. 2   to Veterans Benefits Administration (VBA)

Coordinate with the Office of General Counsel; Office of Resolution Management, Diversity and Inclusion; and the Department of Justice Civil Rights Division to bring the existing Veterans Benefits Administration’s Adjudication Procedures Manual for accommodating veterans with visual impairments into compliance with38 C.F.R. § 14.500, VA Directive 5975, and Executive Order 12250.

No. 3   to Veterans Benefits Administration (VBA)

Develop and implement a quality assurance mechanism to ensure compliance with accessibility requirements, including mandated telephone calls to veterans with visual impairments.

No. 4   to Veterans Benefits Administration (VBA)

Assign accessibility coordinators, publicize their names, and conduct a self-evaluation of policies as outlined in VA accessibility requirements.

No. 5   to Veterans Benefits Administration (VBA)

Coordinate a process to ensure veterans with visual impairments are informed of the availability of accommodations, regardless of their level of disability.

| 21-03630-250 | Summary | Report

Recommendations (3)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

Work with the Centers for Medicare and Medicaid Services to establish a data sharing agreement with VA to limit potential duplicate claim payments.

No. 2   to Veterans Health Administration (VHA)

Identify overpayments made for care provided to dual eligible veterans that were not authorized by VHA and ensure either documentation of care is completed, or VA seeks reimbursement for any care without prior approval.

No. 3   to Veterans Health Administration (VHA)

Make sure all nonemergent community care is preauthorized and that documentation for all authorizations is complete and properly stored before treatment is provided.

Total Monetary Impact of All Recommendations

Open: $ 15,700.00
Closed: $ 0.00

| 21-03309-23 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures governing committees report to the Executive Leadership Council.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures peer reviewers consistently use at least one of the nine aspects of care when conducting peer reviews.

No. 3   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers implement improvement actions recommended by the Peer Review Committee.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete Focused Professional Practice Evaluations within clearly defined time frames.

No. 5   to Veterans Health Administration (VHA)

The Associate Director for Operations evaluates and determines any additional reasons for noncompliance and makes certain that managers maintain a safe and clean environment.

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