Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00589-264 | Audit of VHA's Consolidated Patient Account Center Controls To Prevent Improper Billings for Service-Connected Conditions | Audit | ||
1 We recommended the Under Secretary for Health require Consolidated Patient Account Centers review a statistical sample of bills issued during fiscal years 2015 and 2016 for the treatment of service-connected veterans to identify erroneously billed amounts that require refunds, and use these results to address internal control deficiencies and assess what additional efforts can be taken to identify and refund erroneously billed amounts.
Closure Date:
2 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to provide billing staff read-only access to the Veterans Benefits Management System to identify potential service-connected bills that require review by Revenue Utilization Review nurses.
Closure Date:
3 We recommended the Under Secretary for Health require Consolidated Patient Account Center management establish oversight procedures to review statistical samples of prescriptions prior to generating bills to veterans and to address any identified systemic or facility-specific billing problems.
Closure Date:
4 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise quality assurance reviews to include reviews of pharmacy bills and evaluate whether Revenue Utilization Review nurses correctly validate or make service-connection determinations for veterans’ medical treatment based upon staffing and workload.
Closure Date:
5 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise policy and procedure to require Consolidated Patient Account Center staff to adequately provide and document training for VA medical facility staff regarding specific service-connection determination errors.
Closure Date:
6 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to track and monitor incorrect medical provider service-connection determinations and coordinate training to ensure identified issues are appropriately addressed.
Closure Date:
| ||||
| 15-02583-256 | Review of Alleged Delay of Care and Scheduling Issues at the VAMC in West Palm Beach, FL | Audit | ||
1 We recommended the Director of the West Palm Beach VA Medical Center ensure recruitment efforts are progressing to fulfill cardiology clinic vacancies and that there are sufficient cardiologists for the needs of the Medical Center.
Closure Date:
2 We recommended the Director of the West Palm Beach VA Medical Center ensure all scheduling staff are trained on the requirement to reschedule appointments canceled by the clinic within 14 days of the original appointment date.
Closure Date:
3 We recommended the Director of the West Palm Beach VA Medical Center ensure schedulers are using the clinically indicated or preferred appointment dates when scheduling appointments.
Closure Date:
4 We recommended the Director of the West Palm Beach VA Medical Center ensure supervisors perform the required number of scheduling audits for each scheduler as required by VAMC policy.
Closure Date:
| ||||
| 16-02454-250 | Review of VA’s Readiness To Implement the Digital Accountability and Transparency Act | Audit | ||
1 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Establish milestones to monitor VA’s system modernization efforts. Coordination with the shared service provider should continue to incorporate current and upcoming DATA Act requirements to ensure that they will be met going forward.
Closure Date:
2 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Obtain procurement and grants management system capability that is integrated with the financial system as part of VA’s transition to a shared service provider to the extent feasible.
Closure Date:
3 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Improve communication with, and accountability of, administrations and offices and their points of contact who are responsible for providing data and documentation. Accountability should include timely, complete, and accurate submissions to the Project Management Office.
Closure Date:
4 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Continue working with the points of contact to ensure program information for all funds is submitted as required.
Closure Date:
5 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Identify internal controls and develop standard operating procedures for the processes used to obtain, extract, classify, and summarize data from VA’s financial and management systems to comply with the DATA Act schema.
Closure Date:
6 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
In conjunction with VA’s component organizations, perform an assessment of how business, accounting, and payment processes interact with one another for the purpose of establishing relevant policies and procedures to improve VA’s data quality. This assessment should include VA’s subsidiary systems and their interface status with the general ledger system, that is Financial Management System.
Closure Date:
7 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Ensure complete reconciliations are performed between the subsidiary and general ledger systems. Differences should be researched and resolved to improve data quality.
Closure Date:
8 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Continue to work on minimizing the use of the Management Information Exchange to record journal vouchers that are not linked to obligation and expenditure data by object class or program activity, or devise a mechanism to track such information when recording Management Information Exchange journal vouchers.
Closure Date:
9 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Perform reconciliations between VA’s procurement systems (Electronic Contract Management System and Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system) and Financial Management System to ensure consistency, accuracy, and completeness of financial and procurement data.
Closure Date:
10 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Provide resources for data storage capabilities to improve auditability of data. Specifically, VA should establish a data storage mechanism such as a shared drive to store data received from points of contact or developed internally by the Project Management Office. Such information should be secured, readily available for analysis and requests, validated, and auditable.
Closure Date:
11 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Ensure proper segregation of duties between staff responsible for processing data for submission to the data broker and staff responsible for validating the accuracy and completeness of data prior to submission to the data broker.
Closure Date:
12 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Provide necessary resources to the VA DATA Act Project Management Office to ensure that the office can coordinate the data inventory, mapping, and validation for the required DATA Act Schema data elements.
Closure Date:
13 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Require administration points of contact to respond timely to Project Management Office data requests to ensure that the data elements can be inventoried, mapped, and validated and that gap analyses are performed thoroughly.
Closure Date:
14 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Use the data inventory and mapping to support VA’s move to a shared service provider and ensure full compliance with the DATA Act.
Closure Date:
15 In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Establish procedures for data edits and validations to ensure that DATA Act submissionsare accurate and complete. At a minimum, management should selectively test internalcontrols related to the preparation of data submissions.
Closure Date:
16 In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Assess the impact of the internal control weaknesses, as reported by VA’s financialstatement audit, on DATA Act data, and develop alternative processes to address data quality issues.
Closure Date:
17 In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Continue to maintain communication with the Office of Management and Budget andTreasury regarding VA’s data reporting limitations and progress, and document suchcommunication.
Closure Date:
| ||||
| 16-00566-314 | Clinical Assessment Program Review of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Quality, Safety, and Value Committee be consistently chaired or co-chaired by the Facility Director.
Closure Date:
2 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
3 We recommended that facility clinical managers consistently implement individual improvement actions recommended by the Peer Review Committee and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
5 We recommended that the Patient Safety Manager consistently provide feedback about root cause analysis findings to the individual or department who reported the incident and that facility managers monitor compliance.
Closure Date:
6 We recommended that facility managers ensure carpets and tile floors in patient care areas are clean and monitor compliance.
Closure Date:
7 We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
Closure Date:
9 We recommended that clinicians ensure patients newly prescribed warfarin have an international normalized ratio measurement taken within 7 days of warfarin initiation and that facility managers monitor compliance.
Closure Date:
10 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug-to-drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
Closure Date:
11 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:
12 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior and a Disruptive Behavior Committee/Board.
Closure Date:
13 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
Closure Date:
14 We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
Closure Date:
15 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 the training is documented in employee training records.
Closure Date:
16 We recommended that clinicians enter orders for mammograms in the Computerized Patient Record System and that clinical managers monitor compliance.
Closure Date:
17 We recommended that clinicians screen patients for tetanus vaccinations at clinic visits and that clinical managers monitor compliance.
Closure Date:
18 We recommended that clinicians document all required vaccine administration elements and that clinical managers monitor compliance.
Closure Date:
| ||||
| 16-02551-306 | Healthcare Inspection Veterans Choice Program Dermatology Delays, Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Federal Health Care Center Director ensure that fee department staff take timely action when providers order non-VA care and Choice dermatology consults.
Closure Date:
2 We recommended that the Federal Health Care Center Director ensure that fee department staff take timely action to complete, cancel, or discontinue non-VA care and Choice dermatology consults, as appropriate.
Closure Date:
| ||||
| 16-00558-311 | Clinical Assessment Program Review of the Syracuse VA Medical Center, Syracuse, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
3 We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
4 We recommended that for patients transferred out of the facility, providers consistently include date of transfer and documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
Closure Date:
5 We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and contain a staff/attending physician countersignature and monitor compliance.
Closure Date:
6 We recommended that the facility trend the use of reversal agents in moderate sedation cases, that the facility process adverse events/complications in a similar manner as operating room anesthesia adverse events, and that facility managers monitor compliance.
Closure Date:
7 We recommended that providers include the history of previous adverse experiences with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
Closure Date:
8 We recommended that clinical managers ensure employees who perform or assist with moderate sedation procedures have current training for the provision of moderate sedation care and that training is documented and monitor compliance.
Closure Date:
9 We recommended that the facility establish a Community Nursing Home Oversight Committee.
Closure Date:
10 We recommended that facility managers ensure clinical visits occur within the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
11 We recommended that facility clinical managers ensure clinicians review the continuing need for Patient Record Flags every 2 years and document the review.
Closure Date:
12 We recommended that facility managers ensure all employees receive additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
Closure Date:
13 We recommended that the Facility Director immediately remove unauthorized employees’ access to the medication room, evaluate access for all medication rooms within the facility, and take corrective action to meet Veterans Health Administration requirements.
Closure Date:
| ||||
| 16-04764-266 | Inspection of the VA Regional Office Seattle, Washington | Review | ||
1 We recommended the Seattle VA Regional Office Director implement a plan to ensure traumatic brain injury claims are assigned to qualified Rating Veterans Service Representatives for processing.
Closure Date:
2 We recommended the Seattle VA Regional Office Director implement a plan to provide refresher training on traumatic brain injury and monitor the effectiveness of that training.
Closure Date:
3 We recommended the Seattle VA Regional Office Director implement a plan to ensure Rating Veterans Service Representatives follow second signature policy requirements for traumatic brain injury and special monthly compensation rating decisions.
Closure Date:
4 We recommended the Seattle VA Regional Office Director develop and implement a plan to provide refresher training to Rating Veterans Service Representatives regarding proper procedure for applying effective dates.
Closure Date:
5 We recommended the Seattle VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the end of the due process time period.
Closure Date:
6 We recommended the Seattle VA Regional Office Director implement a plan to conduct comprehensive training for claims establishment staff that emphasizes the importance of ensuring all elements are considered when establishing claims, and assess the effectiveness of that training.
Closure Date:
7 We recommended the Seattle VA Regional Office Director implement a plan to ensure data input at the time of claims establishment are reviewed.
Closure Date:
8 We recommended the Seattle VA Regional Office Director monitor the effectiveness of the training regarding how to properly upload emails into electronic claims folders, and conduct refresher training as necessary.
Closure Date:
9 We recommended the Seattle VA Regional Office Director implement a training plan to ensure all status updates on inquiries are made part of the electronic records, and monitor the effectiveness of that training.
Closure Date:
10 We recommended the Seattle VA Regional Office Director implement a plan to provide oversight and quality review of all types of special controlled correspondence.
Closure Date:
| ||||
| 16-04535-329 | Healthcare Inspection – Alleged Inadequate Mental Health Care, Iowa City VA Health Care System, Iowa City, Iowa | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Under Secretary for Health ensure that facility staff conduct thorough post suicide reviews to include all information that provides valuable context and details related to the event.
Closure Date:
2 We recommended that the System Director ensure that the system No-Show policy and practice for mental health patients is in alignment with the expectations of the Office of Mental Health Operations and that system leaders monitor compliance.
Closure Date:
3 We recommended that the System Director ensure that clinicians update outpatient mental health treatment plans according to applicable requirements and guidance and that system leaders monitor compliance.
Closure Date:
4 We recommended that the System Director ensure that the Mental Health Treatment Coordinator program complies with VHA requirements and guidance, and that system leaders monitor compliance.
Closure Date:
| ||||
| 16-04918-263 | Inspection of the VA Regional Office Indianapolis, Indiana | Review | ||
1 We recommended the Indianapolis VA Regional Office Director ensure and implement local training that complies with Veterans Benefits Administration policy and implement plans to ensure the effectiveness of that training for evaluation of higher-level Special Monthly Compensation claim and ancillary benefits.
Closure Date:
2 We recommended the Midwest District Director implement a plan to ensure the Indianapolis VA Regional Office Director provides oversight and prioritization of proposed rating reduction cases for completion at the end of the due process time period.
Closure Date:
3 We recommended that the Indianapolis VA Regional Office Director provide training to Claims Assistant on how to assign the correct medical classification to claimed disabilities and monitor the effectiveness of that training.
Closure Date:
4 We recommended that the Indianapolis VA Regional Office Director implement a plan to modify the quality review checklist on claims establishment to include “claimed issue with classification” and “special issue” indicators for all claims.
Closure Date:
5 We recommended the Indianapolis VA Regional Office Director implement a plan to comply with Veteran Benefits Administration policy for managing and processing special controlled correspondence.
Closure Date:
6 We recommended the Indianapolis VA Regional Office Director provide training to the Congressional Liaison responsible for processing special controlled correspondence.
Closure Date:
7 We recommended the Indianapolis VA Regional Office Director develop and implement a plan to assess the effectiveness of the special controlled correspondence checklist.
Closure Date:
| ||||
| 15-04374-313 | Administrative Investigation - Improper Approval and Use of Leave, VA Medical Center, Chillicothe, Ohio | Administrative Investigation | ||
1 We recommend the Network Director confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Ms. Hepker.
Closure Date:
2 We recommend the Network Director confer with the Offices of Human Resources and General Counsel to review Dr. Johnston’s improper use of sick leave, and consider whether VA should seek recoupment or waive the improper pay and allowances in accordance with VA Financial Policies and Procedures § 010508.
Closure Date:
3 We recommend the Network Director confer with Ms. Hepker to review and revise the local VAMC leave policy, Policy Memorandum No. 05-01 (Leave Administration), to ensure it is consistent with VA’s policy, VA Handbook 5011, limiting the approval of LWOP to employee’s who are reasonably expected to return to duty.
| ||||
14957