Recommendations
2076
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00392-240 | Inspection of Midwest District 3 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director ensures district leaders follow the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review panel member assignments and report completion.
2 The District Director identifies reasons for noncompliance with documentation requirements of high-risk client contacts and outcomes in RCSNet and the High Risk Suicide Flag SharePoint site, ensures requirements are met, and monitors compliance.
3 The Readjustment Counseling Service Chief Officer considers developing an additional written policy for High Risk Suicide Flag SharePoint disposition and related RCSNet documentation.
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| 25-00194-239 | Healthcare Facility Inspection of the Eastern Oklahoma VA Health Care System in Muskogee | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff follow facility policies and maintain a cleanenvironment.
2 Facility leaders ensure staff develop service-level workflows for the communication of urgent, noncritical test results.
3 Executive leaders monitor the effectiveness of the patient notification process.
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| 25-00228-214 | Review of Clinical Contact Centers to Assess Leadership and Oversight | Review | ||
1 Require the chief operating officer to direct the Veterans Integrated Service Network directors to fully integrate the core services in accordance with policy to improve operational efficiencies and access for veterans.
2 Establish a process requiring medical facility directors to coordinate with the Office of Integrated Veteran Care and the clinical contact centers before setting up or maintaining a local phone queue for services the clinical contact center provides.
3 Require the Office of Integrated Veteran Care to direct the clinical contact center leaders to determine if schedulers are arbitrarily ending calls in the telephone system to remain in after-call work status longer than needed to reduce the number of calls routed to them.
4 Require the Office of Integrated Veteran Care to review and address inconsistencies in guidance on schedulers’ availability.
5 Direct clinical contact center leaders to routinely evaluate and, if needed, address schedulers’ handle time and availability time to improve performance and reduce inefficiencies.
6 Direct the Office of Integrated Veteran Care to include schedulers’ handle time and availability time as part of VA Health Connect’s annual performance plans to make sure clinical contact centers monitor and address these areas.
7 Make sure the Office of Integrated Veteran Care and chief operating officer evaluate VA Health Connect staffing for scheduling and, if necessary, reallocate staff so all clinical contact centers provide core services and meet required performance standards for scheduling.
8 Direct the Office of Integrated Veteran Care to formalize and clarify internal waiver guidance and include examples of the specific evidence that would be required for a clinical contact center not to provide 24-hour services—such as exploring the use of other strategies like routing calls to another service or partnering with other centers to provide coverage.
9 Ensure the assistant under secretary for health for the Office of Integrated Veteran Care and chief operating officer periodically review the clinical contact center waiver submissions and the planned actions to comply with VA Health Connect requirements.
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| 23-03328-197 | The Accuracy of Veteran Readiness and Employment Claims Cannot Be Assessed Because of Insufficient Documentation | Audit | ||
1 Veteran Readiness and Employment should coordinate with VA’s Office of General Counsel to assess the eligibility decision process and ensure all legal and regulatory requirements are accounted for and confirmed by the appropriate staff. If necessary, Veteran Readiness and Employment should update the process to conform with the general counsel’s interpretation of legal requirements.
2 Veteran Readiness and Employment should develop a standard documentation method for verifying eligibility periods, deferrals, extensions, and final eligibility decisions and train appropriate staff, including vocational rehabilitation counselors, on how to properly document eligibility decisions.
3 Veteran Readiness and Employment should develop a quality assurance review process to monitor the accuracy of eligibility decisions.
4 Veteran Readiness and Employment should coordinate with VA’s Office of General Counsel to assess the entitlement requirements and whether those used to confirm and document entitlement decisions are compliant with laws and regulatory requirements. If changes are needed, Veteran Readiness and Employment should update the manual and train appropriate staff accordingly.
5 Veteran Readiness and Employment should develop additional controls to ensure official entitlement decisions in the narrative report are documented in a manner that is clear and would allow for effective oversight from both internal and external entities, such as containing clear documentation of the assessment of employability factors and additional evidence used to substantiate the claim.
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| 23-03357-156 | Better Controls Needed to Accurately Determine Decisions for Veterans’ Nonpresumptive Conditions Involving Toxic Exposure Under the PACT Act | Review | ||
1 Review all processing errors on cases the Office of Inspector General team identified, correct those errors, and report back on the results of those actions.
2 Collaborate with key stakeholders—such as the VA Secretary and representatives from the Office of Field Operations, the Office of General Counsel, and as needed the Board of Veterans’ Appeals—to prioritize consolidating the guidance for PACT Act claims processing into the Adjudication Procedures Manual.
3 Evaluate the effectiveness of control activities specifically for denials of nonpresumptive conditions under toxic exposure risk activity procedures and determine where new or stronger controls are needed.
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| 24-01092-228 | Widespread Failures in Response to Suspected Community Living Center Resident Abuse at the VA New York Harbor Healthcare System in Queens | Hotline Healthcare Inspection | ||
1 The VA New York Harbor Healthcare System Director reviews facility processes to ensure medical and psychosocial health care for residents who report abuse, and staff are educated on the requirements.
2 The VA New York Harbor Healthcare System Director ensures that community living center nursing leaders and factfinding investigators complete factfindings in accordance with Veterans Health Administration policy.
3 The VA New York Harbor Healthcare System Director reviews responses to other incidents of suspected abuse and ensures actions are completed for resolution, including notifications.
4 The VA New York Harbor Healthcare System Director ensures community living center staff are compliant with Veterans Health Administration Prevention and Management of Disruptive Behavior Program education and training requirements.
5 The VA New York Harbor Healthcare System Director ensures community living center nursing and clinical staffs’ electronic health records documentation meets requirements for timeliness, accuracy, and completion, and takes action as needed.
6 The Under Secretary for Health ensures that VHA abuse policy addresses compliance with federal statutes and regulations, including 42 C.F.R. § 483.12, and outlines suspected elder abuse processes to notify leaders, interdisciplinary care team members, VA Police, patients’ families or designees, and state regulatory agencies; and identifies roles and responsibilities of reviewing officials for investigative reviews.
7 The VA New York Harbor Healthcare System Director ensures system abuse policies include required elements to comply with Veterans Health Administration, state, and federal regulations, including 42 C.F.R. § 483.12; and clearly outlines processes for leaders and staff when responding to suspected abuse related to reporting (for example, to interdisciplinary care team members, VA Police, family or designee, and state regulatory agencies); and conducting factfinding investigations.
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| 24-03608-203 | Inadequate Oversight Allowed a Senior Benefits Representative to Inaccurately Authorize Thousands of Decisions | Review | ||
1 Review all processing errors on cases the OIG review team identified, correct those errors to the extent possible, and report back on the results of those actions.
2 Evaluate the effectiveness of control activities specifically for authorization rate outliers and determine whether new or stronger controls are needed.
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| 25-00451-200 | VHA Did Not Effectively Oversee the Use of Manual Journal Vouchers | Audit | ||
1 Develop a plan to ensure manual journal vouchers are justified, documented, and approved before they are entered into the Financial Management System and that they are reviewed after posting to verify accuracy and support compliance, transparency, and audit readiness.
2 Require ongoing training for all staff who prepare, review, or approve manual journal vouchers, including a process to ensure that new employees complete initial training and that refresher courses are provided when policies or tools are updated.
3 Clarify expectations for using macro-enabled journal voucher tools by defining when the standardized macro must be used; establishing a process to communicate macro tool updates and prompt the adoption of newly released versions; and providing guidance, training, and user support to promote correct and consistent application of the tools.
4 Define and communicate clear oversight responsibilities for Veterans Integrated Service Network financial managers by requiring routine monitoring of documentation and compliance at facilities.
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| 23-00324-170 | Loma Linda Healthcare System’s Oversight of Community-Based Outpatient Clinic Contracts Needs Strengthening | Review | ||
1 Strengthen controls in the Office of the Assistant Director to ensure inclusion of staffing monitoring contract requirements, in coordination with the contracting officer, to meet gradual staffing level goals during start-up periods in future community‑based outpatient clinic contracts.
2 Strengthen controls to ensure data used for monitoring contract performance standards are accurate and comply with the methodology required in the contract’s Quality Assurance Surveillance Plan.
3 Review the medical staff-driven phase of the credentialing process, to ensure action plans implemented to expedite the credentialing process are effective.
4 Strengthen controls to ensure contracted staff complete required scheduling training before granting them access to VA’s scheduling system and authorizing them to make veteran appointments.
5 Review the healthcare system’s staffing augmentation plan and coordinate with the contracting officer to ensure the full costs are recovered for all Veterans Health Administration staff who provided services for which the contractor was also compensated.
6 Review the unilateral memorandum related to staffing augmentation, establish a contract modification in compliance with the Federal Acquisition Regulation provisions regarding contract changes, and ensure relevant documentation is maintained in the contract file.
7 Recover government funds expended for Veterans Health Administration staff augmented at contracted community-based outpatient clinics using full cost amounts.
8 Review and enforce staffing contingency plan requirements for the Loma Linda Healthcare System contract, including maximizing the contractor’s use of temporary replacements, or locum tenens, to minimize staffing shortages.
9 Strengthen oversight mechanisms to ensure the enforcement of staffing requirements during contract start-up in future community‑based outpatient clinic contracts before the clinics become operational.
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| 24-03319-213 | Better Guidance and Measures Would Help Optimize the Productivity of Clinical Resource Hub Physicians | Audit | ||
1 Implement procedures to monitor the data used to measure productivity to ensure the data accurately reflect the complete work of clinical resource hub physicians.
2 Work with appropriate officials, such as Office of Primary Care and clinical resource hub leaders, to determine whether hub physicians should be subject to existing productivity measures. If so, issue clear hubs guidance requiring adherence; if not, clearly define what should be used, and issue thorough guidance on the steps hubs must take to measure physician productivity consistently.
3 Clarify oversight responsibilities for monitoring productivity measures, including detailed procedures and actions that should be taken when thresholds are not met.
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