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

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OIG Reports

| 22-01624-143 | Summary | Report

Recommendations (8)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Issue guidance clarifying that allergens are exempt from the public law and include how the determination was reached.

No. 2   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Formalize and communicate the process for manufacturers to request exemptions.

No. 3   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Formalize the internal process for granting exemptions.

No. 4   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Establish a procedure for monitoring covered drugs identified in this report as not commercially sold.

No. 5   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Develop a procedure to monitor covered drugs identified in this report as newly launched to ensure they have an established ceiling price, and make certain they are made available on the Federal Supply Schedule at the end of the 75-day period.

No. 6   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Request that noncompliant manufacturers identified by the Office of Inspector General conduct a self-audit and submit their findings for remediation.

No. 7   to Office of Acquisitions, Logistics, and Construction (OALC); Veterans Health Administration (VHA)

Engage with the Food and Drug Administration to ensure that when manufacturers request new national drug codes, they are made aware of the public law requirements.

No. 8   to Office of Acquisitions, Logistics, and Construction (OALC)

Require contracting staff at the National Acquisition Center to conduct a covered drug check for all of a manufacturer’s drugs when any pharmaceutical Federal Supply Schedule proposal or product addition modification is submitted.

Total Monetary Impact of All Recommendations

Open: $ 28,100,000.00
Closed: $ 0.00

| 22-00236-212 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.

No. 2   to Veterans Health Administration (VHA)

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct comprehensive environment of care inspections at the required frequency

No. 3   to Veterans Health Administration (VHA)

The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.

No. 4   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation within the required time frame for patients with a positive suicide risk screen.

| 22-02666-214 | Summary | Report

Recommendations (2)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 leaders conduct institutional disclosures for applicable sentinel events.

No. 2   to Veterans Health Administration (VHA)

The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete suicide safety plans for patients with a positive suicide risk screen who are determined safe for discharge home from the urgent care center.

| 22-00230-190 | Summary | Report

Recommendations (6)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures peer reviewers consistently document at least one of the nine aspects of care for Level 3 peer reviews.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all final Level 3 peer reviews.

No. 3   to Veterans Health Administration (VHA)

The Director determines the reasons for noncompliance and ensures police document their response times to panic alarm testing in the mental health inpatient unit.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff or Associate Director, Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures cameras used for patient safety monitoring do not record.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff and Associate Director, Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure staff minimize risks of patients’ self-harm in the mental health inpatient unit.

No. 6   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff attempt weekly follow-up until mental health care is established for patients determined as intermediate or high-acute or chronic risk of suicide on the Comprehensive Suicide Risk Evaluation who are discharged home from the Emergency Department.

| 22-00507-211 | Summary | Report

Recommendations (14)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of the patient and third-party contacts, consults with Human Resources and General Counsel Offices, and takes actions as warranted.

No. 2   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director expedites the alignment of the Medora documentation template with the VA and Department of Defense Clinical Practice Guideline and Veterans Crisis Line guidelines for suicide risk assessment classification levels.

No. 3   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director ensures and strengthens the quality management oversight of staff who provide crisis management services, including overtime coverage.

No. 4   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director confirms the retention of crisis management text conversations and establishes supervisory oversight protocols.

No. 5   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director ensures issue briefs accurately reflect the action plan.

No. 6   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director identifies criteria for immediate internal reviews of customers’ deaths by suicide and accidental overdose to identify crisis management and administrative performance improvement actions.

No. 7   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a full review of the patient’s text contact, determines whether an institutional disclosure is warranted, and takes action as indicated.

No. 8   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director monitors compliance with the submission and oversight of notification of a customer’s death, including timely submission of a suicide prevention coordinator consult.

No. 9   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director conducts a review of the interactions between the Director, Quality and Training, and staff in preparation and during the Office of Inspector General healthcare inspection, educates staff on the importance of fully cooperating, responding in an open and transparent manner, and avoiding any appearance of coordination between employees, and take actions as warranted.

No. 10   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director clarifies and strengthens procedures for complaint submission, provides staff training, ensures consistency with the Veterans Health Administration directive, and monitors compliance.

No. 11   to Veterans Health Administration (VHA)

The South Texas Veterans Health Care System Director ensures that processes are established for timely death notification entry in patients’ electronic health records.

No. 12   to Veterans Health Administration (VHA)

The South Texas Veterans Health Care System Director ensures that staff adheres to the January 2022 standard operating procedures for administrative and clinical actions following a patient’s or employee’s death by suicide.

No. 13   to Veterans Health Administration (VHA)

The Veterans Crisis Line Director strengthens processes to ensure discontinuation of caring letters in a timely manner following notification of a patient’s death.

No. 14   to Veterans Health Administration (VHA)

The South Texas Veterans Health Care System Director makes certain that the Suicide Prevention Program ensures full implementation of the Behavioral Health Autopsy Program as required by the Veterans Health Administration.

| 22-02293-188 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Benefits Administration (VBA)

Develop and implement procedures to ensure the Veteran Readiness and Employment Service has properly researched and clearly understands changes to the laws and regulations that govern Chapter 31–only schools and training programs.

No. 2   to Veterans Benefits Administration (VBA)

Review the existing manual requirements for waivers and coordinate with appropriate officials to ensure amendments to 38 United States Code § 3104(b) have been properly implemented and included in the manual.

No. 3   to Veterans Benefits Administration (VBA)

Train all appropriate Veteran Readiness and Employment Service regional office staff to ensure waivers are obtained for each veteran with the required documentation in accordance with the manual before approval to attend a Chapter 31–only school or training program.

No. 4   to Veterans Benefits Administration (VBA)

Coordinate with appropriate officials to determine whether the existing manual guidance for compliance surveys meets the requirements of 38 United States Code § 3693 as it applies to Chapter 31–only schools and training programs, and if necessary, update the manual and train appropriate Veteran Readiness and Employment Service regional office staff accordingly.

No. 5   to Veterans Benefits Administration (VBA)

Develop and implement monitoring processes—to include veteran waivers, compliance surveys, and completeness of electronic folders—to provide Veteran Readiness and Employment Service reasonable assurance that Chapter 31–only schools and training programs are used as intended by law and regulations.

Total Monetary Impact of All Recommendations

Open: $ 13,000,000.00
Closed: $ 0.00

| 22-00234-200 | Summary | Report

Recommendations (5)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.

No. 2   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in Ongoing 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 service chiefs’ reprivileging recommendations are based, in part, on Ongoing Professional Practice Evaluation activities.

No. 4   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee considers professional practice evaluation results in decisions to recommend privileges.

No. 5   to Veterans Health Administration (VHA)

The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures staff complete Comprehensive Suicide Risk Evaluations.

| 23-01011-148 | Summary | Report

Recommendations (4)Toggle Content


OpenClosed - ImplementedClosed - Not Implemented

No. 1   to Veterans Health Administration (VHA)

The under secretary for health to make sure all scheduling guidance and other materials correctly refer to the date that should be used to determine wait-time eligibility for community care.

No. 2   to Veterans Health Administration (VHA)

The under secretary for health to make sure the Office of Integrated Veteran Care provides ongoing oversight to ensure all facilities are using nationally approved scheduling tools.

No. 3   to Veterans Health Administration (VHA)

The under secretary for health to develop an oversight process to verify that schedulers are using the correct dates to calculate wait-time eligibility for community care.

No. 4   to Veterans Health Administration (VHA)

The under secretary for health to develop a mechanism to notify schedulers when it is appropriate to consider wait-time eligibility for community care regardless of which scheduling system schedulers are using.

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