Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-02084-343 | Inspection of VA Regional Office Anchorage, Alaska | Review | ||
1 We recommended the Anchorage VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due
process time period.
Closure Date:
2 We recommended the Anchorage VA Regional Office Director
strengthen oversight to ensure data input at the time of claims
establishment is reviewed for accuracy.
Closure Date:
3 We recommended the Anchorage VA Regional Office Director
implement a plan to monitor the effectiveness of training related to claims establishment procedures.
Closure Date:
4 We recommended the Anchorage VA Regional Office Director provide training for designated congressional liaison staff who process special controlled correspondence and monitor the effectiveness of the training.
Closure Date:
5 We recommended the Anchorage VA Regional Office Director
implement a plan to ensure oversight is strengthened for special
controlled correspondence.
Closure Date:
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| 16-00838-348 | Review of Alleged Adverse Effect on Patient Care Due to Removal of a Computer-Assisted Survey Instrument | Audit | ||
1 We recommended the Acting Assistant Secretary for Information and Technology implement appropriate controls to ensure that Class III software is not installed on VA networks without a formal technical review and authority to operate, and that training is provided to OIT Region 1 staff on the treatment of Class III software.
Closure Date:
| ||||
| 16-00753-338 | Review of Alleged Use of Wrong VA Funds To Purchase IT Equipment | Audit | ||
1 We recommended the Veterans Integrated Service Network 23 Director consult with VA’s Office of General Counsel and take necessary corrective actions to correct the funding error related to the purchase of WiFi and cable television services and ensure that appropriate funds are used for future information technology purchases in accordance with VA policy and VA’s Office of General Counsel guidance.
Closure Date:
2 We recommended the Veterans Integrated Service Network 23 Director work with the Chief Financial Officer to determine if an Antideficiency Act violation occurred and take action as deemed appropriate.
Closure Date:
3 We recommended the Acting Assistant Secretary for Information and Technology update the 2016 IT/Non-IT Policy to address the dissemination of decisions and issues that may be systemic across VA.
Closure Date:
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| 15-01415-382 | Healthcare Inspection – Alleged Transcatheter Aortic Valve Replacement Program Issues, VA Palo Alto Health Care System, Palo Alto, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that providers document clinical judgement, coordination of care, communication with the patient or referring facility, and an accurate plan of care from initial assessment to procedure for transcatheter aortic valve replacement patients.
Closure Date:
| ||||
| 17-00266-349 | Inspection of the VA Regional Office Winston-Salem, North Carolina | Review | ||
1 We recommended the Winston-Salem Regional Office Director develop and implement a plan to monitor the effectiveness of training on higher-level special monthly compensation and ancillary benefits claims at the Winston-Salem VA Regional Office.
Closure Date:
2 We recommended the Winston-Salem VARO Director develop and implement a plan to ensure secondary reviewers accurately evaluate higher-level special monthly compensation and ancillary benefits claims at the Winston-Salem VA Regional Office.
Closure Date:
3 We recommended the North Atlantic District Director implement a plan to ensure oversight and prioritization of proposed rating reduction cases at the Winston-Salem VA Regional Office.
Closure Date:
4 We recommended that the Winston-Salem VARO Director ensure management provides a consistent quality review process addressing all elements required when establishing claims in the electronic record.
Closure Date:
5 We recommended the Winston-Salem VA Regional Office Director ensure VSC staff receive all mandatory annual training on claims establishment procedures.
Closure Date:
6 We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure the Public Contact Coach and Congressional Liaisons adhere to Veterans Benefits Administration policy when processing special controlled correspondence.
Closure Date:
7 We recommended the Winston-Salem VA Regional Office Director provide standardized training to Congressional Liaisons on processing special controlled correspondence.
Closure Date:
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| 16-02151-320 | Review of Alleged Payment Issues at Kerrville VA Hospital Kerrville, Texas | Audit | ||
1 We recommended the director of the STVHCS instruct PRMC to stop advising veterans that they may be liable for pre-authorized NVC.
Closure Date:
| ||||
| 17-00936-385 | OIG Determination of VHA Occupational Staffing Shortages FY 2017 | National Healthcare Review | ||
1 We recommended that the Acting Under Secretary for Health ensure that the Veterans Health Administration implements staffing models for critical need occupations.
Closure Date:
2 We recommended that the Acting Under Secretary for Health review the Veterans Health Administration report on regrettable losses and implement effective measures to reduce such losses.
Closure Date:
3 We recommended that the Acting Under Secretary for Health continue incorporating data that predict changes in veteran demand for health care into its staffing model.
Closure Date:
4 We recommended that the Acting Under Secretary for Health continue assessing the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.
Closure Date:
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| 16-02241-375 | Healthcare Inspection – Delayed Access to Primary Care, Contaminated Reusable Medical Equipment, and Follow-Up of Registered Nurse Staffing Concerns, Southern Arizona VA Health Care System, Tucson, Arizona | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that primary care appointment scheduling processes are assessed and action is taken to ensure timely access for new and established patients.
Closure Date:
| ||||
| 17-02073-317 | Inspection of the VA Regional Office, Detroit, Michigan | Review | ||
1 We recommended the Detroit VA Regional Office Director develop and implement a plan to improve the accuracy of the second-signature review process for higher-level Special Monthly Compensation and ancillary benefits.
Closure Date:
2 We recommended the Detroit VA Regional Office Director implement a plan to conduct comprehensive training for Claims Assistants that emphasizes the importance of ensuring all elements are considered when establishing claims, and assess the effectiveness of that training.
Closure Date:
3 We recommended the Detroit VA Regional Office Director implement a plan to modify the quality review checklist on claims establishment to include claim label and claimed issue classification indicators.
Closure Date:
4 We recommended the Detroit VA Regional Office Director implement a plan to ensure staff adhere to Veterans Benefits Administration policy and use the correct dates of claim for end products 500 used to manage special controlled correspondence.
Closure Date:
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| 16-00548-361 | Clinical Assessment Program Review of the Wilmington VA Medical Center, Wilmington, Delaware | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Environment of Care Committee meeting minutes track actions taken in response to identified deficiencies to closure.
Closure Date:
2 We recommended that facility managers ensure all fire extinguishers are inspected monthly and marked with the correct date and monitor compliance.
Closure Date:
3 We recommended that employees document when they access information technology network rooms by using the visitor logs and that facility managers monitor compliance.
Closure Date:
4 We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive annual competencies for the types of reusable medical equipment they reprocess.
Closure Date:
5 We recommended that hemodialysis unit employees wear gloves when handling patient equipment and that the hemodialysis unit manager monitors compliance.
Closure Date:
6 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating warfarin treatment.
Closure Date:
7 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in the competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
Closure Date:
8 We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility collect and report data on patient transfers out of the facility and that facility managers monitor compliance.
Closure Date:
10 We recommended that for patients transferred out of the facility, clinicians consistently include documentation of patient or surrogate informed consent and of medical and behavioral stability in transfer documentation and that facility managers monitor compliance.
Closure Date:
11 We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
Closure Date:
13 We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
Closure Date:
14 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
15 We recommended that the facility update its policy on the community nursing home program to include all elements required by Veterans Health Administration policy.
Closure Date:
16 We recommended that a VA physician order or approve all therapies that are at VA expense.
Closure Date:
17 We recommended that facility managers ensure the community nursing home program office scans existing paper health records into electronic health records and develops a process to scan new records as they are received.
Closure Date:
18 We recommended that the facility update its policy on preventing and managing disruptive and violent behavior.
Closure Date:
19 We recommended that the VA Police Officer and the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
Closure Date:
20 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that training is documented in employee training records.
Closure Date:
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15039