OIG Reports

No. 1   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures primary care teams adhere to Veterans Health Administration policies related to mental health screenings, consult management, and care coordination, and monitors compliance.

No. 2   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director reviews processes for consult scheduling, including community care referrals, and ensures patients are offered timely appointments in the pain management clinic, per Veterans Health Administration policies.

No. 3   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director confirms pain management clinic staff receive education of Veterans Health Administration policies related to mandatory suicide risk assessments.

No. 4   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director develops a process to ensure that Emergency Department staff communicate patients’ referral information from the Veterans Crisis Line to Emergency Department providers.

No. 5   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures that suicide prevention staff documentation is complete and accurate, and actions are taken to resolve issues identified in Veterans Crisis Line referrals prior to closure.

No. 6   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director reviews Veterans Health Administration policy and guidance regarding completed suicides on VA campuses and actions required as a result, and provides education to relevant staff.

No. 7   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director ensures completion of accurate and comprehensive Behavioral Health Autopsies and Family Interview Tool Contact forms.

No. 8   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director reviews and evaluates the peer review process to ensure peer reviews are conducted according to Veterans Health Administration policy.

No. 9   to Veterans Health Administration (VHA)

The Charlie Norwood VA Medical Center Director reviews and evaluates the February 2022 clinical review to identify open actions and monitors the implementation and efficacy of action items to closure.

No. 1   to Office of Management

Assess the iFAMS configuration to determine whether integration with the payroll subsystems can be accomplished to resolve some of the payroll-related issues that require the need for expenditure transfers.

No. 2   to Veterans Health Administration (VHA)

Establish guidance that outlines the type of documentation required to support the amounts identified in the manual journal vouchers when processing expenditure transfers.

No. 3   to Veterans Health Administration (VHA)

Require medical facility staff have documented authority, through proper delegation, to make purchases.

No. 4   to Veterans Health Administration (VHA)

Verify that medical facility staff segregate duties so that the same person is not both authorizing and receiving goods and services.

No. 5   to Veterans Health Administration (VHA)

Make certain the purchase card holder is not the requestor or approver for the purchase.

No. 6   to Veterans Health Administration (VHA)

Ensure contracting officer’s representatives know and understand their duties and responsibilities for the certification and payment of invoices.

No. 7   to Veterans Health Administration (VHA)

Check vendors’ compliance with contract terms to include the comparison of invoiced amounts with the contract line-item unit costs.esponse to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.

No. 8   to Veterans Health Administration (VHA)

Ensure that medical facility staff track the receipt of goods to make certain they are the correct quantity.

No. 9   to Veterans Health Administration (VHA)

Conduct an assessment of lessons learned from the emergency response to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.

No. 1   to Veterans Health Administration (VHA)

The Executive Director evaluates and determines any additional reasons fornoncompliance and ensures leaders conduct institutional disclosures for allapplicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures service chiefs complete Ongoing Professional PracticeEvaluations.

No. 1   to Veterans Health Administration (VHA)

The VA San Diego Healthcare System Director ensures the accuracy of code green documentation.

No. 2   to Veterans Health Administration (VHA)

The VA San Diego Healthcare System Director evaluates the VA San Diego Healthcare System Memorandum 116A-06, “Code Green/Code Yellow,” and aligns definitions, requirements, and responsibilities with purpose and practice, and monitors compliance.

No. 1   to Veterans Health Administration (VHA)

The VA Black Hills Health Care System Director reviews the sexual harassment policy to ensure that leaders and supervisors can identify, thoroughly investigate, and respond to sexual harassment allegations.

No. 2   to Veterans Health Administration (VHA)

The VA Black Hills Health Care System Director reviews the actions of the Compensated Work Therapy and Transitional Residence program manager related to the identified patient’s case and takes action as needed.

No. 3   to Veterans Health Administration (VHA)

The VA Black Hills Health Care System Director ensures that facility policy addresses the safety and rights of patients who are both VA employees and participants in the Transitional Residence program.

No. 1   to Veterans Health Administration (VHA)

The VA Black Hills Health Care System Director continues to monitor and track the identified action plan through to completion.

No. 2   to Veterans Health Administration (VHA)

The VA Black Hills Health Care System Director reviews the evidence and independently determines if the state licensing board should be notified.

No. 1   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 using objective criteria accepted by the practitioner.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Medical Executive Council reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.

No. 3   to Veterans Health Administration (VHA)

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

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.