Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-02742-77 | Review of Research Service Equipment and Facility Management, Eastern Colorado Health Care System | Audit | ||
1 The OIG recommended the VA Eastern Colorado Health Care System Director establish a policy requiring the Research Service implement a process to identify all accountable equipment annually that does not have a barcode label, and ensure these items are communicated to the Logistics Service so they receive a barcode label and are recorded in the automated inventory system.
Closure Date:
2 The OIG recommended the VA Eastern Colorado Health Care System Director develop an action plan that would ensure all Research Service sensitive information technology equipment is assigned to an information technology equipment inventory list.
Closure Date:
3 3. The OIG recommended the VA Eastern Colorado Health Care System Director implement a training program to ensure Information Technology, Research, and Logistics Service staffs are properly trained to enable them to identify and place sensitive information technology equipment under control.
Closure Date:
4 The OIG recommended the VA Eastern Colorado Health Care System Director implement a policy requiring the Logistics Service perform recurring, at least annually, quality reviews of Research Service automated equipment data to identify and correct incomplete, inaccurate, and unreliable records, maintain copies of the reviews, and provide the completed reviews to the director.
Closure Date:
5 The OIG recommended the VA Eastern Colorado Health Care System Director implement a policy requiring the Logistics Service perform recurring quality reviews, at least annually, to ensure equipment transaction records are maintained, logically organized, and easily accessible for assigned research equipment, in accordance with policy.
Closure Date:
6 The OIG recommended the VA Eastern Colorado Health Care System Director develop a local policy requiring the Logistics Service to perform recurring reviews of inventory dates for all Research Service accountable equipment and sensitive items, to ensure all equipment has been inventoried on an annual basis, which is from the month of completion to the next 12-month period, as required by VA Handbook 7002.
Closure Date:
7 The OIG recommended the VA Eastern Colorado Health Care System Director implement a procedure to ensure compliance with the VA Handbook 6500.1 requirement to attach VA Form 0751, Information Technology Equipment Sanitization Certificate, to VA Form 2237, Request, Turn-In, and Receipt for Property or Services, prior to disposal of sensitive information technology equipment.
Closure Date:
8 The OIG recommended the VA Eastern Colorado Health Care System Director take steps necessary to ensure required Report of Survey actions listed in VA Handbook 7002 are completed for the missing items reported lost by the Research Service on the eight Reports of Survey initiated in calendar year 2015.
Closure Date:
9 The OIG recommended the VA Eastern Colorado Health Care System Director require the accountable officer to follow policy, establish, and maintain a Report of Survey register by fiscal year, to track, monitor, and ensure required actions are completed timely.
Closure Date:
10 The OIG recommended the VA Eastern Colorado Health Care System Director ensure there are an adequate number of officials who have the required training to complete Report of Survey actions so Reports of Survey can be fully processed, timely.
Closure Date:
11 The OIG recommended the VA Eastern Colorado Health Care System Director implement a mechanism to ensure all Research Service Custodial Officers complete their required annual Custodial Officer’s training.
Closure Date:
12 The OIG recommended the VA Eastern Colorado Health Care System Director ensure Delegation of Authority letters for all current Research Service Custodial Officers are completed in accordance with VA Handbook 7002.
Closure Date:
13 The OIG recommended the VA Eastern Colorado Health Care System Director ensure all materials and specimens are stored in a freezer with a remote temperature monitoring system.
Closure Date:
14 The OIG recommended the VA Eastern Colorado Health Care System Director ensure exterior doors on Research Service buildings are repaired so they consistently lock upon closure.
Closure Date:
15 The OIG recommended the VA Eastern Colorado Health Care System Director ensure all exterior doors to Research Service buildings are secured by self-closing doors with automatic locking upon closure with access by keycard or a system that is equal to or exceeds the security of a keycard system.
Closure Date:
16 The OIG recommended the VA Eastern Colorado Health Care System Director establish procedures to timely decommission vacant laboratories, and collect, store or dispose of unused chemicals and personally identifiable information in accordance with applicable policies.
Closure Date:
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| 17-05407-141 | Comprehensive Healthcare Inspection Program Review of the Samuel S. Stratton VA Medical Center, Albany, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the Executive Committee of the Medical Staff uses the results of Ongoing Professional Practice Evaluations in the determination of whether to recommend continuation of licensed independent practitioners’ privileges and monitors 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 Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from the Chief, Business Office Revenue-Utilization Review.
Closure Date:
4 The Facility Director ensures the Patient Safety Manager or designee provides feedback about root cause analysis actions to the reporting individuals or departments and monitors the Patient Safety Manager’s compliance.
Closure Date:
5 The Associate Director ensures environment of care rounds are conducted in all areas of the facility at the required frequency and monitors compliance.
Closure Date:
6 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
Closure Date:
7 The Associate Director ensures medical biohazardous waste storage rooms are secured and monitors compliance.
Closure Date:
8 The Facility Director ensures that controlled substances inspectors perform controlled substances order verification as required and monitors inspectors’ compliance.
Closure Date:
9 The Facility Director ensures controlled substances inspectors complete monthly pharmacy prescription pad inventories and monitors inspectors’ compliance.
Closure Date:
10 The Chief of Staff ensures providers communicate mammogram results to patients and monitors providers’ compliance.
Closure Date:
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| 17-03399-150 | Healthcare Inspection—Inadequate Intensivist Coverage and Surgery Service Concerns, Gulf Coast Veterans Healthcare System, Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 We recommended that the System Director continue to follow through on incomplete actions as discussed in Issues 1 and 2 of this report.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director provide oversight of intensive care unit and Surgery Service-related operations until corrective actions are completed and conditions have been resolved.
Closure Date:
3 We recommended that the System Director take action as appropriate related to Physicians A and B and their improper electronic health record documentation as discussed in this report.
Closure Date:
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| 17-05409-140 | Comprehensive Healthcare Inspection Program Review of the Martinsburg VA Medical Center, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Acting Chief of Staff ensures the development and utilization of privilege-specific criteria for Focused Professional Practice Evaluations and monitors compliance.
Closure Date:
2 The Acting Chief of Staff ensures the development and utilization of service-specific criteria for Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
3 The Associate Director ensures all required environment of care team members are assigned to and consistently participate on environment of care rounds and monitors compliance.
Closure Date:
4 The Facility Director ensures that Controlled Substance Inspectors complete controlled substance order verifications and monitors compliance.
Closure Date:
5 The Acting Chief of Staff ensures mammogram results are electronically linked to the radiology order and monitors compliance.
Closure Date:
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| 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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| 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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| 17-00253-93 | 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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15039