Recommendations
2120
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00900-230 | Audit of Community-Based Outpatient Clinic Contracts | Audit | ||
1 Review and update VHA Directive 1660.07, “Medical Sharing/Affiliate National Program Office,” to delegate all required program office responsibilities for the community-based outpatient clinic contracts throughout the program’s life cycle to an appropriate headquarters-level office or collaboration of offices, as defined in VHA Directive 1217, “VHA Operating Units” and VA’s Acquisition Lifecycle Framework.
2 Develop and implement procedures for a headquarters-level office to monitor overall compliance with contract requirements and use the results to reassess program policies or contract requirements.
3 Develop a formal feedback process, such as a program life cycle review process, for contracting officers and contracting officer representatives, medical facilities, and contractors who work on community-based outpatient clinic contracts to provide lessons learned, issues encountered, and other feedback about establishing new clinics and the performance at the clinics.
4 Conduct an assessment of contractor compliance with all active community-based outpatient clinic contracts, then evaluate whether the community-based outpatient clinic contract performance metrics are measurable, reasonable, and attainable.
5 Coordinate with the Office of General Counsel to determine whether creating a separate contract line item from the operational costs for contracted community-based outpatient clinics to pay start-up costs, including construction costs, would assist in the administration of these contracts and increase competition among contractors; then update the community-based outpatient clinic performance work statement template to reflect any change made as a result of this consideration.
6 Assess how medical centers create and maintain the billable roster for community-based outpatient clinic contracts; based on the results, develop and implement efficient, accurate, and consistent procedures for developing and maintaining the billable rosters.
7 Coordinate with the VA medical centers that have VA-contracted community-based outpatient clinics to conduct a risk assessment to evaluate the responsibilities, time requirements, and qualifications of community-based outpatient clinic contracting officer representatives; then publish clear guidance or recommendations for facilities to make sure they have appropriately experienced, trained, and certified staff to oversee the performance of community-based outpatient clinic contracts.
8 Assess the certification levels of the CORs assigned to all CBOC contracts and make recommendations to the medical centers for assigning appropriately experienced CORs or to provide any additional training or assistance to existing CORs, if necessary.
9 Develop and implement procedures to require VA medical centers and contracting offices to verify that the Office of Information Technology can meet start-up requirements for new community-based outpatient clinic locations as part of the contract review process.
10 Review and evaluate how contracting offices rated community-based outpatient clinic contractors in the Contractor Performance Appraisal Reporting System, and if necessary, develop and disseminate additional guidance or training to contracting offices to help them appropriately rate community-based outpatient clinic contractors in accordance with the performance metrics and the broad categories in the Contractor Performance Appraisal Reporting System.
11 Determine whether positive and negative performance incentives should be used for community-based outpatient clinic contracts to motivate the contractors to provide high-quality health care, in accordance with FAR 37.6, FAR 16.202, and FAR 16.402-2.
a. If performance incentives are appropriate for community-based outpatient clinic contracts, ensure the Medical Sharing/Affiliate Office coordinates with the Office of General Counsel to develop and implement measurable, reasonable, and defensible positive and negative performance incentives.
b. If performance incentives are not appropriate for community-based outpatient clinic contracts, ensure the Medical Sharing/Affiliate Office and each network contracting office documents in the contract files the reasons why performance incentives are not used to the maximum extent practicable, in accordance with FAR 16.402-2 and FAR 37.6.
12 Develop and implement procedures to identify, evaluate, and incorporate commercial practices and contract types into the community-based outpatient clinic contract requirements templates before publishing updated versions, in accordance with 38 U.S.C. § 8153 and FAR part 10; the procedures should evaluate whether the contract payment structure for community-based outpatient clinic contracts is consistent with current commercial practices.
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| 25-01515-67 | Review of Availability of On-Call Interventional Radiology Services and a Related Patient Transfer at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana | Hotline Healthcare Inspection | ||
1 The Richard L. Roudebush VA Medical Center Director establishes a process to ensure that changes impacting the availability of clinical services to patients are clearly communicated to all relevant staff members.
Closure Date:
2 The Richard L. Roudebush VA Medical Center Director ensures that residents, fellows, and clinical service leaders understand and follow the requirement to document complete and pertinent information, including assessments and recommendations, in patients’ electronic health records.
3 The Richard L. Roudebush VA Medical Center Director educates providers on the requirements related to completing a clinical disclosure when an adverse event occurs, such as a delay in care.
4 The Richard L. Roudebush VA Medical Center Director ensures the episode of care related to the patient’s transfer is reviewed to determine whether an institutional disclosure is needed in accordance with Veterans Health Administration requirements, and takes action as warranted.
5 The Richard L. Roudebush VA Medical Center Director monitors to ensure that Joint Patient Safety Reporting system reports are included or rejected in accordance with Veterans Health Administration guidance.
6 The Richard L. Roudebush VA Medical Center Director ensures a comprehensive review of the patient’s care and transfer is completed to identify factors that contributed to the patient’s unnecessary transfer and takes action as warranted.
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| 24-03542-57 | Mental Health Inspection of the VA Tampa Healthcare System in Florida | Mental Health Inspection Program | ||
1 The Facility Director ensures the Mental Health Executive Council includes veteran representation.
2 The Associate Chief of Staff, Mental Health ensures the development and implementation of written processes for staff training, education, and recovery-oriented services.
Closure Date:
3 The Associate Chief of Staff, Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.
4 The Facility Director develops and implements written processes to monitor and track compliance with state involuntary commitment requirements.
5 The Chief of Staff ensures discharge instructions for veterans include appointment locations in easy-to-understand language.
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6 The Facility Director directs staff to comply with VA S.A.V.E. training requirements and monitors for compliance.
7 The Facility Director directs inpatient unit staff, volunteers, and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.
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| 25-00200-48 | Healthcare Facility Inspection of the VA Eastern Colorado Health Care System in Aurora | Healthcare Facility Inspection | ||
1 Facility leaders direct staff to conduct a risk assessment on liquid nitrogen storage, to include the small devices stored in examination rooms, and implement changes if needed.
2 Facility leaders determine appropriate supply storage locations and, for any supplies stored outside of the defined locations, implement a process to ensure staff identify and remove expired supplies.
3 Facility leaders ensure staff label opened multidose medications with expiration dates.
4 Facility leaders ensure staff store clean and dirty items separately.
5 The Director ensures staff implement processes to prevent repeat environment of care findings.
6 The OIG recommends facility leaders ensure the facility has a policy for the communication of test results and staff develop service-level workflows that align with VHA requirements.
7 Veterans Integrated Service Network 19 leaders assess the staffing needs for the facility’s radiology service and provide additional resources to ensure services are readily available to patients.
8 Veterans Integrated Service Network 19 leaders evaluate the reasons for delays in uploading images and reporting test results and assist the facility’s community care leaders to mitigate future delays.
9 Executive leaders monitor root cause analysis improvement actions through completion, monitor outcome measures, and ensure staff implement processes to sustain the improvements.
10 Facility leaders attain appropriate primary care staffing and manageable panel sizes to ensure patients have timely access to high-quality care.
Closure Date:
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| 25-00814-62 | Assessment of Cytopathology Processing at the Oklahoma City VA Medical Center in Oklahoma | Hotline Healthcare Inspection | ||
1 The Oklahoma City VA Health Care System Director, with Pathology and Laboratory Medicine Service leaders, conducts a comprehensive review of the quality of care for the four patients identified in this report, including determinations of cytopathology processing delays and assessment of patient harm, and takes action as warranted.
2 The Oklahoma City VA Health Care System Director ensures that routine non-gynecological turnaround time corrective actions are documented and monitored for effectiveness, as required by the Veterans Health Administration.
3 The Oklahoma City VA Health Care System Director conducts a comprehensive review of the quality of care provided by the Chief of Pathology and Laboratory Medicine Service, identifies deficiencies, and takes action as warranted.
4 The Oklahoma City VA Health Care System Director reviews the Pathology and Laboratory Medicine Service event reporting requirements for variance events and ensures completion according to facility policy and Veterans Health Administration requirements.
5 The Oklahoma City VA Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates patient safety event reporting processes within the Pathology and Laboratory Medicine Service, and ensures completion according to Veterans Health Administration requirements.
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| 25-00975-234 | Inspection of Information Security at the VA Spokane Healthcare System in Washington | Information Security Inspection | ||
1 Implement vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
2 Implement a more effective baseline configuration process to ensure network devices and databases are running authorized software that is configured to approved baselines and free of vulnerabilities.
3 Perform a cost-benefit analysis and implement appropriate controls within the federal Electronic Health Record to limit disclosure of veteran personally identifiable information based on job responsibility.
4 Segregate the duties of maintaining key stock and making keys.
5 Place network infrastructure equipment in a communications closet or approved enclosure to restrict access to only authorized personnel.
6 Complete the installation of grounding measures for all telecommunications closets to protect information technology equipment against electromagnetic pulse attack or electrostatic discharge. Ensure the work completed by contractors adheres to the requirements as defined in the work order.
7 Add anti-ram barriers to protect all sides of a fueling station’s fuel tank.
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| 25-00529-219 | Audit of Integrated Financial and Acquisition Management System Access Controls | Audit | ||
1 Implement a plan with the Office of Acquisition and Logistics Project Management Office to ensure system access is more granular and the intent of the principle of least privilege is met.
2 Ensure all roles and accesses, including those provided by default access, are reviewed and certified periodically as required.
3 Implement a permanent solution to provide supervisors and information owners with visibility of all roles and accesses, including those provided by default access, granted to users.
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| 25-00214-61 | Healthcare Facility Inspection of the VA Central California Health Care System in Fresno | Healthcare Facility Inspection | ||
1 The Executive Director ensures staff receive education about badge holders’ responsibilities in preventing unauthorized access to VA facilities and computer systems and safeguarding electronic databases including electronic health care records.
2 The Executive Director ensures signs are present and accurate throughout the facility.
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3 The Executive Director ensures staff maintain privacy curtains, preventive maintenance on medical equipment, and splash resistant bottom shelves on supply carts.
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4 The Executive Director ensures staff monitor patient care areas for expired, damaged, and contaminated medications and remove them as needed.
5 The Executive Director ensures staff store medications in pharmaceutical grade refrigerators.
6 The Executive Director ensures primary care staffing is sufficient for patients to receive appropriate health care.
7 The Executive Director reviews staffing levels for the Housing and Urban Development–Veterans Affairs Supportive Housing program and takes action as needed.
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| 25-00243-56 | Healthcare Facility Inspection of the VA Sierra Nevada Health Care System in Reno | Healthcare Facility Inspection | ||
1 The Medical Center Director ensures staff properly store clean medical equipment.
2 Facility leaders develop written workflows for each service to ensure timely communication of test results to providers and patients.
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| 25-00238-44 | Healthcare Facility Inspection of the VA Battle Creek Healthcare System in Michigan | Healthcare Facility Inspection | ||
1 The Director ensures staff keep the environment clean and safe.
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2 The Director ensures Healthcare Technology Management Service staff inspect, test, and properly document all medical equipment maintenance per their required schedule.
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3 The Director ensures staff implement processes to prevent repeat environment of care findings identified in this report.
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4 Facility leaders ensure service-level workflows include each staff member’s role in the communication of test results process.
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15277