Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-01695-94 | Recruitment, Relocation, and Retention Incentives for VHA Positions Need Improved Oversight | Audit | ||
1 Establish internal control procedures to ensure recruitment, relocation, and retention incentive documentation is appropriately maintained in accordance with VA policy and guidance.
2 Enforce procedures to ensure Veterans Integrated Service Network human resources offices properly review recruitment, relocation, and retention incentive documentation for compliance with VA policy.
3 Enforce quality control checks to ensure Veterans Integrated Service Networks fulfill requirements for maintaining recruitment, relocation, and retention incentives documentation.
4 Establish accountability measures to ensure Veterans Integrated Service Networks’ quality control and oversight responsibilities are risk-based and fulfilled in a timely manner.
5 Evaluate resource requirements and establish accountability measures to ensure quality control and oversight responsibilities are risk-based and fulfilled in a timely manner.
6 Evaluate the retention incentive awards for the 28 employees identified in this report who received payments after the incentive period ended, terminate the incentive if it was not recertified, determine whether recoupment of funds is warranted, and take action if appropriate.
7 Assess retention incentive payment data to identify awards that have been paid for over one year and determine whether each has been appropriately recertified or should be terminated.
Closure Date:
8 Establish oversight procedures to ensure retention incentives are reviewed annually, recertified if appropriate, or otherwise terminated to ensure payments are not continued after the expiration date.
Total Monetary Impact of All Recommendations
Open: $345,532,795
Closed: $0
Total: $345,532,795
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| 24-00600-136 | Healthcare Facility Inspection of the VA St. Louis Healthcare System in Missouri | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders determine appropriate supply storage locations, and for any supplies stored outside these defined locations, implement a process to ensure staff identify and remove expired supplies.
Closure Date:
2 The OIG recommends facility leaders ensure video laryngoscope supplies are readily available and not expired.
Closure Date:
3 The OIG recommends the Director ensures staff keep patient care areas clean and safe.
Closure Date:
4 The OIG recommends the Director ensures staff complete required preventive maintenance for biomedical equipment.
Closure Date:
5 The OIG recommends facility leaders develop service-level workflows and processes to monitor communication of test results to patients.
Closure Date:
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| 24-00612-119 | Healthcare Facility Inspection of the VA Puget Sound Health Care System in Seattle, Washington | Healthcare Facility Inspection | ||
1 The OIG recommends the Executive Director ensures homeless program staff have sufficient access to government vehicles to effectively function in their positions.
Closure Date:
2 The OIG recommends the Executive Director ensures Housing and Urban Development–Veterans Affairs Supportive Housing program staff have access to cell phones to independently provide services to homeless veterans.
Closure Date:
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| 24-01083-112 | VBA’s Special Monthly Compensation Calculator in the Veterans Benefits Management System for Rating Did Not Always Produce Accurate Results | Review | ||
1 Ensure all erroneous scenarios in the Veterans Benefits Management System for Rating special monthly compensation calculator identified in this review are corrected and certify the results to the VA Office of Inspector General.
2 Establish a plan to conduct additional testing of the Veterans Benefits Management System for Rating special monthly compensation calculator to ensure its accuracy.
Closure Date:
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| 24-01322-103 | Failure to Flag Fiduciaries Who Were Removed Results in Risk to Vulnerable Beneficiaries | Review | ||
1 Update the Fiduciary Program Manual to specify when a removed fiduciary should be flagged as “Do Not Appoint” and ensuring that staff understand if they are responsible for adding the flag.
Closure Date:
2 Develop and provide training on updated Fiduciary Program Manual procedures on flagging barred individuals or entities as “Do Not Appoint” and include a mechanism to ensure that fiduciary hub staff have taken and understand the training.
Closure Date:
3 Update the quality review process to include ensuring that fiduciaries are flagged “Do Not Appoint” when required.
Closure Date:
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| 24-00524-104 | Better Communication and Oversight Could Improve How the Pain Management, Opioid Safety, and Prescription Drug Monitoring Program Manages Funds | Audit | ||
1 Instruct the program to communicate pertinent annual funding guidance related to Pain Management, Opioid Safety, and Prescription Drug Monitoring Program initiatives before the start of the upcoming fiscal years so that Veterans Integrated Service Networks and medical facilities can adequately plan and take appropriate hiring actions needed to spend their funds.
Closure Date:
2 Ensure the program communicates pertinent funding information related to Pain Management, Opioid Safety, and Prescription Drug Monitoring Program initiatives with key personnel—such as program coordinators and Veterans Integrated Service Network and medical facility leaders.
Closure Date:
3 Ensure the program clarifies and defines requirements for pain management teams in the new Veterans Health Administration Directive 1151, Pain Management and Opioid Safety.
4 Establish means to periodically validate the status information of facilities’ pain management teams.
5 Require the program and the chief operating officer to assess and ensure corrective actions are taken to address each medical facility’s lack of progress in achieving compliance with the requirement to have a pain management team as mandated by the Jason Simcakoski Memorial and Promise Act.
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| 24-00596-129 | Healthcare Facility Inspection of the VA Oklahoma City Healthcare System in Oklahoma | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure all veterans and visitors, including those who require mobility assistance, have safe and accessible pathways to clinical areas during elevator repairs.
Closure Date:
2 The OIG recommends facility leaders ensure staff complete and document preventive maintenance for medical equipment.
Closure Date:
3 The OIG recommends the Chief of Staff and the Associate Director, Patient Care Services ensure staff record their attendance at meetings where staff monitor the communication of test result data.
Closure Date:
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| 24-00394-122 | Inspection of Select Vet Centers in Midwest District 3 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Evanston, La Crosse, and Milwaukee Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Evanston, Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
3 District leaders and the Gary Area Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Evanston, Gary Area, and Milwaukee Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the La Crosse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
7 District leaders determine reasons why the closing of the Milwaukee Vet Center resulted in multiple communication failures, and ensure all clients are notified of the new location, the Vet Center Call Center has accurate information, and websites include correct location and phone number information.
Closure Date:
8 The Readjustment Counseling Service Chief Officer considers developing written guidance for vet center closure and temporary relocation processes including oversight responsibilities.
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| 24-00617-118 | Healthcare Facility Inspection of the VA Augusta Health Care System in Georgia | Healthcare Facility Inspection | ||
1 The OIG recommends the Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication and takes actions as needed.
Closure Date:
2 The OIG recommends the Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other Veterans Integrated Service Network leaders were aware of, but did not address, facility leaders’ unprofessional behavior and communication, and takes actions as needed.
Closure Date:
3 The OIG recommends the Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system, resolve medical supply deficiencies, and monitor actions for sustained improvement.
4 The OIG recommends facility leaders develop action plans to ensure providers communicate test results to patients timely.
5 The OIG recommends the Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.
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| 24-02359-123 | Deficiencies in Emergency Care for a Female Veteran at Martinsburg VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Martinsburg VA Medical Center Director reviews communication between emergency department staff to ensure timely patient care coordination, and takes action as warranted.
2 The Martinsburg VA Medical Center Director ensures emergency department nurses monitor, assess, and document patient care as required by Veterans Health Administration and Martinsburg VA Medical Center policy, and monitors compliance.
3 The Martinsburg VA Medical Center Director ensures processes are in place to ensure blood transfusions are administered according to policy, and monitors compliance.
Closure Date:
4 The Martinsburg VA Medical Center Director conducts a review of actions implemented as a result of the factfinding to include administrative actions and performance improvement plans and ensures quality of care concerns have been remediated, and takes action as warranted.
5 The Martinsburg VA Medical Center Director evaluates the functionality of emergency room equipment, including an exam table with footrests, for conducting gynecologic examinations with dignity and comfort, and takes action as warranted.
Closure Date:
6 The Martinsburg VA Medical Center Director reviews concerns related to fire department overtime practices, takes action as appropriate, and follows up to ensure compliance.
Closure Date:
7 The Martinsburg VA Medical Center Director reviews the transport delay for the abdominal pain patient, and takes action as appropriate.
Closure Date:
8 The Martinsburg VA Medical Center Director reviews the factfinding related to transportation concerns, ensures an adequate review is conducted, and takes action as warranted.
Closure Date:
9 The Martinsburg VA Medical Center Director ensures all reported patient safety concerns related to emergency transport delays are investigated to identify root causes and contributing factors that require action to prevent future events.
Closure Date:
10 The Martinsburg VA Medical Center Director ensures clear guidance is in place for clinical and administrative staff on the use of facility emergent and non-emergent transport resources.
Closure Date:
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15303