Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-03324-123 | Administrative Investigation - Conflict of Interest, Nepotism, and False Statements, VA Office of General Counsel, Washington, DC | Administrative Investigation | ||
1 The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Mr. Fleck.
Closure Date:
2 The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Ms. KW.
Closure Date:
3 The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the total amount of funds unlawfully expended to pay for Ms. KW’s salary since her initial VA appointment on January 8, 2017, and ensures that a bill of collection is issued to Ms. KW in that amount.
Closure Date:
4 The VA Deputy Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate corrective action to take concerning Ms. KW’s VA appointment and takes such action.
Closure Date:
5 The VA Deputy Secretary confers with VA’s Designated Agency Ethics Official to ensure Deputy General Counsel for Legal Policy staff members receive appropriate ethics training as related to our findings in this report.
Closure Date:
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| 17-00253-93 | Review of Resident and Part-Time Physician Time and Attendance at Oklahoma City VA Health Care System | Audit | ||
1 The OIG recommended the Oklahoma City VA Health Care System Director ensure local policies and procedures are established for resident educational activity record keeping, monitoring resident participation in assigned educational activities, and reconciling VA educational activity with invoices submitted by the University of Oklahoma College of Medicine.
Closure Date:
2 The OIG recommended the Oklahoma City VA Health Care System Director ensure all staff involved in educational activity record keeping receive initial and annual refresher training on how to maintain the records.
Closure Date:
3 The OIG recommended the Oklahoma City VA Health Care System Director establish procedures to ensure agreed-upon salary and benefits rates for residents are properly approved by the Office of Academic Affiliations.
Closure Date:
4 The OIG recommended the Oklahoma City VA Health Care System Director require the medical school to submit adequate documentation tosupport its benefits rate for Social Security and Medicare costs for residents who are exempt from those taxes.
Closure Date:
5 The OIG recommended the Oklahoma City VA Health Care System Director ensure the Designated Education Officer certifies final invoices for payment after all discrepancies identified in the reconciliation process are resolved.
Closure Date:
6 The OIG recommended the Oklahoma City VA Health Care System Director ensure the Designated Education Officer approves and maintains copies of the approved agreements for all off-site educational activities each academic year.
Closure Date:
7 The OIG recommended the Oklahoma City VA Health Care System Director review all academic year 2015–2016 invoices and initiateactions to recover overpayments from the medical school for residents who worked at non-VA facilities without prior written approval of the VA site directors and Designated Education Officer.
Closure Date:
8 The OIG recommended the Oklahoma City VA Health Care System Director appoint a team to conduct periodic audits of the disbursement agreement, including educational activity record keeping at the service and section level, reconciliation procedures, and the accuracy of the invoices submitted by the medical school.
Closure Date:
9 The OIG recommended the Oklahoma City VA Health Care System Director ensure service chiefs conduct required reviews of part-time physicians to ensure they are working as scheduled.
Closure Date:
10 The OIG recommended the Oklahoma City VA Health Care System Director require service chiefs and supervisors ensure part-time physicians on adjustable work schedules enter their work hours in the electronic subsidiary record on a daily basis.
Closure Date:
11 The OIG recommended the Oklahoma City VA Health Care System Director ensure that all overdue reconciliations of part-time physicians’ adjustable work hour agreements identified in the report are performed and actions are taken to address over- and underpayments.
Closure Date:
12 The OIG recommended the Oklahoma City VA Health Care System Director establish procedures to verify that all reconciliations of part-time physicians’ adjustable work hour agreements are completed timely.
Closure Date:
13 The OIG recommended the Oklahoma City VA Health Care System Director ensure service chiefs conduct quarterly reviews of all part-time physicians on adjustable work schedules.
Closure Date:
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| 17-01856-135 | Comprehensive Healthcare Inspection Program Review of the Fayetteville VA Medical Center, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the Advisors’ compliance.
Closure Date:
3 The Facility Interim Director ensures that required representatives of the interdisciplinary group consistently attend meetings and review utilization management data, and monitors the group’s compliance.
Closure Date:
4 The Facility Interim Director ensures that the Patient Safety Manager submits an annual patient safety report to facility leaders at the completion of each fiscal year and monitors compliance.
Closure Date:
5 The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating patients on anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
6 The Chief of Staff ensures providers consistently document patient or surrogate informed consent and identify the receiving provider for patients transferred out of the facility and monitors the providers’ compliance.
Closure Date:
7 The Chief of Staff ensures that clinicians consistently communicate pertinent patient information to the receiving facility when patients are transferred out of the facility and monitors the clinicians’ compliance.
Closure Date:
8 The Associate Director ensures that the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
9 The Chief of Staff ensures that acceptable providers perform suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
10 The Chief of Staff ensures that acceptable providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of the referral and monitors providers’ compliance.
Closure Date:
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| 17-05424-142 | Comprehensive Healthcare Inspection Program Review of the VA Illiana Health Care System, Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 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 the Service Chiefs’ compliance.
Closure Date:
2 The Chief of Staff ensures all required members attend the Utilization Management Committee meetings on an ongoing basis and monitors compliance.
Closure Date:
3 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
Closure Date:
4 The Associate Director ensures that temperature monitoring occurs in all dry food storage areas and monitors compliance.
Closure Date:
5 The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Closure Date:
7 The Chief of Staff ensures ordering providers communicate mammogram results to patients and monitors providers’ compliance.
Closure Date:
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| 15-04745-48 | Review of Alleged Unsecured Patient Database at the VA Long Beach Healthcare System | Audit | ||
1 The OIG recommended the Under Secretary for Health ensure the Spinal Cord Injury program complies with VA’s Privacy Program and information security requirements for all veteran sensitive data collected.
Closure Date:
2 The OIG recommended the Executive Director for the National Spinal Cord Injury Program Office discontinue the use of unauthorized versions of Microsoft Access for the storage of Spinal Cord Injury program data and implement an approved system to support its data storage and analysis needs.
Closure Date:
3 The OIG recommended the Acting Assistant Secretary for Information Technology ensure that VA’s Field Security Services and Privacy Service implement improved procedures to identify unauthorized uses of Sensitive Personal Information and train the facility information security officers and privacy officer to ensure that appropriate corrective actions are taken.
Closure Date:
4 The OIG recommended VA’s Field Security Services and Privacy Service conduct a formal review of Spinal Cord Injury projects to identify acceptable disclosures of veteran Sensitive Personal Information and ensure that appropriate safeguards are implemented to protect the confidentiality of veteran data.
Closure Date:
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| 16-01750-79 | Review of Timeliness of the Appeals Process | Review | ||
1 The OIG recommended the acting Under Secretary for Benefits continue to monitor the effectiveness of the Veterans Benefits Administration’s appeals realignment and increased resources, towards meeting its established targets related to appeals processing timeliness.
Closure Date:
2 The OIG recommended the acting Under Secretary for Benefits monitor the effectiveness of the Caseflow application to ensure Board of Veterans’ Appeals decisions are timely controlled and assigned to the appropriate VA Regional Office or the Appeals Resource Center.
Closure Date:
3 The OIG recommended the acting Under Secretary for Benefits implement a plan to amend Veterans Benefits Administration’s procedures for closing appeals records to prevent appeals being closed prematurely.
Closure Date:
4 The OIG recommended the acting Under Secretary for Benefits remind staff of their responsibilities when processing remands and recertifying appeals to the Board of Veterans’ Appeals, and implement a plan to ensure compliance.
Closure Date:
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| 17-01764-143 | Comprehensive Healthcare Inspection Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors compliance.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors at the Alvin C. York campus consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
Closure Date:
3 The Facility Director ensures clinicians document patient education for patients receiving anticoagulation medication and monitors compliance.
Closure Date:
4 The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee and monitors compliance.
Closure Date:
5 The Chief of Staff ensures providers consistently document patient or surrogate informed consent and the patient’s medical and behavior stability when patients are transferred out of the facility and monitors the providers’ compliance.
Closure Date:
6 The Chief of Staff ensures providers countersign the acceptable designees’ transfer/progress notes when patients are transferred out of the facility and monitors compliance.
Closure Date:
7 The Associate Director ensures that environment of care rounds are conducted at the required frequency and correctly documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
8 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
9 The Associate Director ensures ventilation grills are clean and ceiling tiles are properly maintained and monitors compliance.
Closure Date:
10 The Chief of Staff ensures radiation safety signage is posted in each radiation area and monitors compliance.
Closure Date:
11 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
12 The Associate Director ensures all mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
13 The Chief of Staff ensures that providers include review of abnormalities of major organ systems in the history and physical exams and/or pre-sedation assessments and monitors compliance.
Closure Date:
14 The Chief of Staff ensures that providers inform patients when the provider performing a moderate sedation procedure is not the provider listed on the informed consent for the procedure and document the patient’s assent to the change and monitors compliance.
Closure Date:
15 The Chief of Staff ensures clinical employees who perform, assist with, or supervise moderate sedation procedures have current moderate sedation training and monitors their compliance.
Closure Date:
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| 15-04678-114 | Review of Alleged Hazardous Construction Conditions at the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma | Audit | ||
1 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure contracting officer’s representatives comply with duties assigned in the Delegation of Authority Memo.
Closure Date:
2 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure that on future contracts, the Chief, Engineering Service, assign contracting officer’s representatives who have experience commensurate with delegated responsibilities in accordance with the Federal Acquisition Regulation.
Closure Date:
3 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure personnel follow established Veterans Health Administration policies on safety inspections.
Closure Date:
4 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, clarify the implementation of the safety inspections in Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017, to ensure the safety inspections are not performed routinely or in a discernable pattern.
Closure Date:
5 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure the assignment of a safety officer in accordance with Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017.
Closure Date:
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| 17-05402-137 | Comprehensive Healthcare Inspection Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors members’ compliance.
Closure Date:
2 The Chief of Staff ensures the Infection Prevention Committee consistently documents discussions of the high-risk elements and analysis of surveillance data and monitors compliance.
Closure Date:
3 The Facility Director ensures that 1-day reconciliation of controlled substance refills to automated dispensing units in patient care areas and 1-day reconciliation of returns to pharmacy stock are performed consistently during controlled substance inspections, and the Facility Director monitors compliance.
Closure Date:
4 The Facility Director ensures that 72-hour pharmacy inventories are consistently completed during controlled substance inspections in pharmacy areas and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that the geriatric evaluation program receives the required oversight and that quality improvement data are regularly reviewed and documented in committee minutes, and the Chief of Staff monitors compliance.
Closure Date:
6 The Chief of Staff ensures that geriatric evaluation program registered nurses perform the required patient assessments and monitors the nurses’ compliance.
Closure Date:
7 The Chief of Staff ensures ordering providers or designees communicate mammogram results to patients within the required timeframe and monitors providers’ compliance.
Closure Date:
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| 17-00753-78 | Audit of the Personnel Suitability Program | Audit | ||
1 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness implement the monitoring program required by policy and establish robust management oversight of the personnel suitability program.
Closure Date:
2 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness report the results of program monitoring activities and obtain corrective action plans from the Veterans Health Administration.
Closure Date:
3 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness establish and enforce quality and performance metrics for the personnel suitability program.
Closure Date:
4 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness evaluate human capital needs for program oversight and facilitate the delegation or brokering of duties necessary to manage the background investigation workload.
Closure Date:
5 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness coordinate with the Executive in Charge, Office of the Under Secretary for Health, to implement a plan to review the suitability status of all Veterans Health Administration personnel and correct delinquencies to ensure a properly vetted workforce.
Closure Date:
6 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, improve management oversight of the personnel suitability program at VA medical facilities and ensure background investigations are properly initiated and adjudicated nationwide, and internal control mechanisms required by policy are properly implemented.
Closure Date:
7 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, execute VA requirements to improve the governance of the personnel suitability program.
Closure Date:
8 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, evaluate human capital needs and coordinate appropriate resources to manage personnel suitability workload at VA medical facilities.
Closure Date:
9 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness develop and execute a project management plan to ensure sufficient and appropriate data are collected in support of suitability program objectives.
Closure Date:
10 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness ensure that personnel suitability investigation data are fully evaluated and reliable for program tracking and oversight.
Closure Date:
11 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, coordinate with the Assistant Secretary for Operations, Security, and Preparedness to implement a plan to correct current data integrity issues and improve the accuracy of personnel suitability program data.
Closure Date:
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14957