Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-04919-210 | Processing Inaccuracies Involving Veterans' Intent to File Submissions for Benefits | Audit | ||
1 The OIG recommended the Under Secretary for Benefits take steps to prioritize the modernization of functionality within the Veterans Benefits Management System to assist rating personnel with assigning correct effective dates related to intent to file.
Closure Date:
2 The OIG recommended the Under Secretary for Benefits implement a plan to conduct a special review of claims with intent to file submissions from March 24, 2015, through September 30, 2017, during which payment changes occurred, to determine whether rating personnel assigned correct effective dates when awarding compensation benefits.
Closure Date:
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| 17-05248-241 | Denied Posttraumatic Stress Disorder Claims Related to Military Sexual Trauma | Audit | ||
1 The Under Secretary for Benefits reviews all denied military sexual trauma related claims since the beginning of FY 2017, determines whether all required procedures were followed, takes corrective action based on the results of the review, renders a new decision as appropriate, and reports the results back to the Office of Inspector General.
Closure Date:
2 The Under Secretary for Benefits focuses processing of military sexual trauma related claims to a specialized group of Veterans Service Representatives and Rating Veterans Service Representatives.
Closure Date:
3 The Under Secretary for Benefits requires an additional level of review for all denied military sexual trauma related claims and holds the second level reviewers accountable for accuracy.
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4 The Under Secretary for Benefits conducts special focused quality improvement reviews of denied military sexual trauma related claims and takes corrective action as needed.
Closure Date:
5 The Under Secretary for Benefits updates the current training for processing military sexual trauma related claims, monitors the effectiveness of the training, and takes additional actions as necessary.
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6 The Under Secretary for Benefits updates the development checklist for military sexual trauma related claims to include specific steps claims processors must take in evaluating such claims in accordance with applicable regulations, and requires claims processors to certify that they completed all required development action for each military sexual trauma-related claim.
Closure Date:
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| 18-00618-261 | Comprehensive Healthcare Inspection Program Review of the Erie VA Medical Center, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that the peer reviewer identifies one or more of the Eleven Aspects for Review of Care in the completion of peer reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that the Ongoing Professional Practice Evaluation process includes the development and utilization of service- and practitioner-specific data and monitors compliance.
Closure Date:
3 The Associate Director of Patient Care Services ensures that staff follow medication administration, storage, and disposal policies and monitors compliance.
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| 17-05381-258 | Postoperative Care Concerns for a Vascular Surgical Patient at the Martinsburg VA Medical Center, West Virginia | Hotline Healthcare Inspection | ||
1 The Martinsburg VA Medical Center Director evaluates the coordination of care processes at the Petersburg Community Based Outpatient Clinic and takes action as necessary based on the findings.
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2 The Martinsburg VA Medical Center Director ensures the development and implementation of a policy or standard operating procedure for the management of health emergencies at the Petersburg Community Based Outpatient Clinic, and Petersburg Community Based Outpatient Clinic staff receive training on the policy or standard operating procedure.
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3 The Martinsburg VA Medical Center Director evaluates the Petersburg Community Based Outpatient Clinic Patient Aligned Care Team patient health record documentation for accurate and clinically-relevant statements and takes action as necessary based on the findings.
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| 17-04003-222 | Program of Comprehensive Assistance for Family Caregivers: Management Improvements Needed | Audit | ||
1 The Executive in Charge, Veterans Health Administration, will establish a governance environment for the Program of Comprehensive Assistance for Family Caregivers to ensure medical facilities process veteran applications within the required 45-day timeliness standard, consistently monitor veterans and their caregivers, adequately document the results and changes in veterans’ health status, and adjust the level of support provided or discharge veterans and their caregivers, as appropriate.
Closure Date:
2 The Executive in Charge, Veterans Health Administration, will take steps to ensure caregiver support coordinators are properly applying eligibility criteria with processes, such as pre- or post-approval reviews, to ensure the accuracy of all veteran eligibility determinations.
Closure Date:
3 The Executive in Charge, Veterans Health Administration, will update Directive 1152, Caregiver Support Program, to include a well-defined process for documenting changes in veterans’ health conditions during monitoring sessions to determine if those changes warrant a reassessment of the need for care or the level of care.
Closure Date:
4 The Executive in Charge, Veterans Health Administration, will establish assessment guidelines that caregiver support coordinators should follow when a veteran’s need for care changes.
Closure Date:
5 The Executive in Charge, Veterans Health Administration, will make sure that Veterans Integrated Service Network directors designate program leads at the network level with responsibility for Program of Comprehensive Assistance for Family Caregivers oversight.
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6 The Executive in Charge, Veterans Health Administration, will assess the extent to which current staffing levels at medical facilities are adequate to implement the Program of Comprehensive Assistance for Family Caregivers, as intended.
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| 18-00621-245 | Comprehensive Healthcare Inspection Program Review of the VA Ann Arbor Healthcare System, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Facility managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
Closure Date:
2 The Associate Director and Assistant Director ensure required team members participate on Environment of Care rounds and monitors compliance.
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3 The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
Closure Date:
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| 18-04633-254 | Review of Environment of Care Conditions at Mississippi VA-Contracted Clinics | Hotline Healthcare Inspection | ||
1 The Facility Director requires a team of subject matter experts to complete comprehensive reviews of the community based outpatient clinics’ compliance with environment of care and other contract requirements, and initiate corrective action plans, as needed
Closure Date:
2 The Facility Director ensures that responsible managers and team members provide consistent oversight of community based outpatient clinics operations in accordance with contract requirements.
Closure Date:
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| 18-00619-242 | Comprehensive Healthcare Inspection Program Review of the Dayton VA Medical Center, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that the assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
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3 The Chief of Staff ensures that the interdisciplinary group review UM data on an ongoing basis and monitors compliance.
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4 The Chief of Staff ensures that Service Chiefs complete all required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors compliance.
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5 The Associate Director ensures environment of care rounds are conducted in all areas of the Facility at the required frequency and monitors compliance.
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6 The Associate Director ensures that Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
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7 The Associate Director ensures all medical equipment is identified as safe for patient use and monitors compliance.
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8 The Chief of Staff ensures that geriatric evaluation performance improvement activities are conducted, documented, and reviewed by an appropriate leadership board and monitors compliance.
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9 The Chief of Staff ensures providers perform geriatric medical evaluations and monitors compliance.
Closure Date:
10 The Chief of Staff ensures that clinicians accurately identify and implement geriatric evaluation plan of care interventions and monitors compliance.
Closure Date:
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| 17-05401-240 | Comprehensive Healthcare Inspection Program Review of the Beckley VA Medical Center, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that service line managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that service line managers collect Ongoing Professional Practice Evaluation data utilizing assessments by providers with similar training and privileges and monitors compliance.
Closure Date:
3 The Associate Director ensures environment of care rounds are conducted at the required frequency and documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
4 The Associate Director ensures required team members participate on environment of care rounds and that attendance is recorded in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
5 The Facility Director ensures that deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
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6 The Facility Director ensures that the controlled substances inspectors consistently perform controlled substances order verification as required and monitors compliance.
Closure Date:
7 The Chief of Staff ensures that mammogram results are electronically linked to the radiology orders and monitors compliance.
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8 The Associate Director for Patient Care Services ensures that nursing staff involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
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| 18-01012-228 | Comprehensive Healthcare Inspection Program Review of the Chillicothe VA Medical Center, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures practitioners’ Focused Professional Practice Evaluations include clearly delineated timeframes and monitors compliance.
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2 The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Closure Date:
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15039