Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-02618-424 | Audit of Veteran Wait Time Data, Choice Access, and Consult Management in VISN 6 | Audit | ||
1 We recommended the Under Secretary for Health establish a method to monitor and ensure Veterans Integrated Service Network compliance with scheduling requirements.
Closure Date:
2 We recommended the Director of Veterans Integrated Service Network 6 ensure that staff at all VA medical facilities use the referring provider’s clinically indicated date, when available, or documented veteran’s preferred appointment date, when scheduling new patient appointments.
Closure Date:
3 We recommended the Director of Veterans Integrated Service Network 6 ensure VA medical facilities conduct required scheduler audits and take corrective actions as needed based on audit results.
Closure Date:
4 We recommended the Under Secretary for Health implement monitoring controls to ensure the third-party administrators return authorizations after 2 business days for urgent care and 5 business days for routine care if an appointment had not been scheduled.
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5 We recommended the Director of Veterans Integrated Service Network 6 ensure Non-VACare Coordination staffing is sufficient to timely administer the requirements of the Choice Program.
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6 We recommended the Under Secretary for Health implement controls to ensure the third party administrators create an appointment for the veteran within 5 business days of receiving an authorization.
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7 We recommended the Under Secretary for Health to ensure all data required to manage the third party administrator contracts provided by the VA and the third party administrators is complete, accurate, and timely.
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8 We recommended the Director of Veterans Integrated Service Network 6 ensure services monitor and timely address consults pending greater than 7 days.
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9 We recommended the Director of Veterans Integrated Service Network 6 identify and implement best practices to timely schedule appointments for consults upon receipt and review by the receiving specialty care clinicians.
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10 We recommended the Director of Veterans Integrated Service Network 6 establish a mechanism to routinely audit closed consults to ensure they are in accordance with Veterans Health Administration consult business rules, and take corrective actions as needed based on audit results.
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| 15-04925-469 | Evaluation of Human Immunodeficiency Virus Screening in Veterans Health Administration Outpatient Clinics | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinical staff offer HIV screening as part of routine medical care and that managers monitor compliance.
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2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians document informed consent for HIV testing and that managers monitor for compliance.
VA Office
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| 16-00574-151 | Clinical Assessment Program Review of the Overton Brooks VA Medical Center, Shreveport, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
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2 We recommended that Environment of Care Committee meeting minutes consistently document corrective actions taken to address rounds deficiencies and consistently track actions taken in response to identified deficiencies to closure.
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3 We recommended that facility managers ensure ventilation grills and floors in patient care areas are clean and monitor compliance.
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4 We recommended that the facility repair rusted equipment in patient care areas or remove it from service.
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5 We recommended that facility managers ensure sinks in patient nourishment kitchens are clean and monitor compliance.
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6 We recommended that the hemodialysis unit manager ensure sinks and floors are clean and monitor compliance.
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7 We recommended that the hemodialysis unit manager ensure clean and dirty items are stored separately and monitor compliance.
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8 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
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9 We recommended that clinicians consistently provide transition follow-up to inpatients with newly prescribed anticoagulant medications in accordance with local policy and that facility managers monitor compliance.
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10 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and obtain required laboratory tests during warfarin treatment at the frequency required by local policy.
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11 We recommended that the facility collect and report data on patient transfers out of the facility as required by local policy.
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12 We recommended that facility managers ensure transfer notes are written by a staff/attending physician or are written by an accceptable designee and contain a staff/attending physician countersignature.
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13 We recommended that providers include the evaluation of previous adverse events with anesthesia in the history and physical and pre-sedation assessment and that facility managers monitor compliance.
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14 We recommended that facility managers complete exclusion review documentation when community nursing home annual reviews note four or more exclusionary criteria.
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15 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 and monitor compliance.
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16 We recommended that the facility implement an Employee Threat Assessment Team and that the VA Police Officer and Risk Manager consistently attend Disruptive Behavior Committee meetings.
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17 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to appeal Patient Record Flag placement.
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18 We recommended that facility managers ensure appropriate individuals conduct debriefings after incidents of disruptive or violent behavior and monitor compliance.
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19 We recommended that facility managers ensure all employees receive Level 1 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.
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20 We recommended that community based outpatient clinic/primary care clinic employees consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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| 14-00750-143 | Healthcare Inspection – Documentation of Patient Enrollment Concerns in Home Telehealth John D. Dingell VA Medical Center Detroit, Michigan | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that home telehealth staff be retrained and follow the Veterans Health Administration home telehealth process of care and documentation requirements.
Closure Date:
2 We recommended that the Facility Director ensure that documentation accurately reflects patients’ home telehealth enrollment status as described in this report.
Closure Date:
3 We recommended that the Facility Director review the circumstances surrounding the entry of Home Telehealth Program monthly monitor notes in electronic health records of patients discussed in this report with the Office of Human Resources and the Office of General Counsel and take appropriate action as necessary.
Closure Date:
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| 15-01436-456 | Audit of VBA’s Automated Burial Payments | Audit | ||
1 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, review the improper payments identified in this report and take appropriate corrective actions when warranted.
Closure Date:
2 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, strengthen controls to ensure intended recipients meet entitlement requirements before authorizing automated burial payments.
3 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with the requirement under the United States Code of Federal Regulations that proof of death be submitted prior to the release of automated burial payments.
Closure Date:
4 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with United States Code of Federal Regulations related to automated burial payments and recipients’ entitlement requirements prior to authorizing payments.
Closure Date:
5 We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, ensure quality assurance reviews determine whether staff inappropriately discontinued veterans’ disability benefits and assess whether spouses met entitlement requirements to receive automated burial payments.
Closure Date:
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| 15-01900-142 | Healthcare Inspection – Echocardiography Scheduling and Quality of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that routine, outpatient echocardiography studies are scheduled in accordance with Veterans Health Administration policy.
Closure Date:
2 We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) for possible disclosure to the patient with delayed echocardiography described in this report and take appropriate action, if any.
Closure Date:
3 We recommended that the Facility Director ensure that echocardiography technicians are offered opportunities for re-training and continuing education to improve the quality of the echocardiography image acquisition.
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4 We recommended that the Facility Director ensure that cardiology managers establish performance improvement activities for the echocardiography technicians in accordance with facility policy.
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| 15-01818-213 | Review of Alleged Improperly Sole Sourced Ophthalmology Service Contracts at the Phoenix VA Health Care System | Audit | ||
1 We recommended the Procurement and Logistics Office, Service Area Office West Director ensure Network Contracting Office 18 contracting officers maintain required contracting documentation in the Electronic Contract Management System, as required by VA Procurement Policy Memorandum, Mandatory Usage of VA's Electronic Contract Management System.
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2 We recommended the Phoenix VA Health Care System Director ensure the just over $12.4 million in unauthorized commitments are ratified in accordance with VA Directive 7401.7, Unauthorized Commitments and Ratification.
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3 We recommended the Phoenix VA Health Care System Director develop a business case to evaluate the hiring of VA ophthalmologists and the use of Non-VA Care options, such as the Patient-Centered Care Program and as defined in the Veterans Access, Choice, and Accountability Act.
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4 We recommended the Phoenix VA Health Care System Director ensure staff are aware of Federal Acquisition Regulation sections 6.301 and 3.101-1 related to sole-source contracting and standards of conduct.
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| 15-02189-336 | Review of Alleged Waste of Funds on a Cloud Brokerage Service Contract | Audit | ||
1 We recommended the Assistant Secretary for Information and Technology implement improved controls to ensure the effective oversight of information technology projects and compliance with information technology project management procedures in order to ensure delivery of value.
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2 We recommended the Assistant Secretary for Information and Technology enforce the use of the Project Management Accountability System or Veteran-focused Integration Process on all Office of Information and Technology software development projects to ensure that such efforts will provide an adequate return on investment.
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3 We recommended the Assistant Secretary for Information and Technology establish oversight mechanisms to ensure all VA-developed software costs are funded with Information Technology Systems appropriations.
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| 15-03401-76 | Review of Alleged Human Resources Delays at the Atlanta VA Medical Center | Audit | ||
1 We recommended the Medical Center Director assess the human resources program at the Atlanta VA Medical Center to develop an action plan to ensure all medical center staff have appropriate background investigations and determinations are accurately recorded.
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2 We recommended the Medical Center Director ensure all suitability adjudicators receive the mandatory training and background investigation required for the position.
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3 We recommended the Medical Center Director provide training to all human resources staff on the requirements of the personnel suitability program to include generally accepted resources and tools to standardize the processing of background investigations.
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4 We recommended the Medical Center Director ensure the Atlanta VA Medical Center human resources staff, to include the Drug-Free Workplace Program Coordinators and Medical Review Officers, are properly trained on the requirements of the Drug-Free Workplace Program and the responsibilities of their positions.
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5 We recommended the Medical Center Director review the Drug-Free Workplace Program on a regular basis to ensure compliance with regulations and that employees hired during screening gaps are subject to corrective testing.
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| 15-04673-333 | Review of VHA’s Implementation of the Veterans Choice Program | Audit | ||
1 We recommended the Under Secretary for Health streamline processes and procedures for accessing care under the Veterans Choice Program.
Closure Date:
2 We recommended the Under Secretary for Health develop accurate forecasts of demand for care purchased in the community.
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3 We recommended the Under Secretary for Health simplify requirements for network providers to bill for services under the Veterans Choice Program.
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4 We recommended the Under Secretary for Health ensure eligible veterans are not financially liable for the full cost of treatment authorized under the Veterans Choice Program.
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5 We recommended the Under Secretary of Health ensure community providers are paid in a timely manner under the Veterans Choice Program.
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6 We recommended the Under Secretary for Health review the Veterans Choice Program to determine if growth of provider networks is being limited by allowing reimbursement below Medicare rates.
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15039