Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00075-449 | Combined Assessment Program Follow-Up Review of Environment of Care at the VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that surgical intensive care unit floors are clean and that damaged bathroom fixtures on the surgical intensive care unit are repaired or replaced.
Closure Date:
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| 14-04578-371 | Audit of VA’s Recruitment, Relocation, and Retention Incentives | Audit | ||
1 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to ensure recruitment and relocation incentives are fully justified and authorized before being included on vacancy announcements for hard-to-fill positions or before the final selectee is identified in cases where a position is not filled through a vacancy announcement.
Closure Date:
2 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for the Corporate Senior Executive Management Office to ensure Senior Executive Service recruitment and relocation incentives are fully justified and authorized before being included on vacancy announcements for hard-to-fill positions or before the final selectee is identified in cases where a position is not filled through a vacancy announcement.
Closure Date:
3 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor compliance with its employee certification requirement before relocation incentives are authorized for payment.
Closure Date:
4 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls to monitor the Corporate Senior Executive Management Office’s compliance with the employee certification requirement before Senior Executive Service relocation incentives are authorized for payment.
Closure Date:
5 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor facilities’ compliance with developing workforce and succession plans to reduce the risk of long-term reliance on retention incentives.
Closure Date:
6 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls to monitor the Corporate Senior Executive Management Office’s compliance with developing workforce and succession plans to reduce the risk of long-term reliance on retention incentives for Senior Executives.
Closure Date:
7 We recommended the Assistant Secretary for Human Resources and Administration monitor the Corporate Senior Executive Management Office to ensure its technical review and recommendations to the VA Chief of Staff regarding Senior Executive Service incentives are prudent and in full compliance with VA Handbook 5007/46.
Closure Date:
8 We recommended the Assistant Secretary for Human Resources and Administration assess the feasibility of limiting the number of consecutive years employees in specific occupations or groups of employees in specific occupations can receive retention incentive payments.
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9 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor facilities’ compliance with VA Handbook 5007/46 requirements to initiate debt collection from individuals who did not fulfill their recruitment, relocation, or retention incentive service obligations.
Closure Date:
10 We recommended the Assistant Secretary for Human Resources and Administration examine the capabilities of the HR Smart personnel system to determine the extent to which it is possible to develop an incentive-specific automated alert that notifies Human Resources personnel when employees have outstanding recruitment, relocation, or retention incentive service obligations.
Closure Date:
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| 14-02890-352 | Review of Alleged Improper Non-VA Community Care Consult Practices at Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Audit | ||
1 We recommended the Director, Ralph H. Johnson VAMC, initiate an additional clinical review regarding the patient identified in this report, and take action as appropriate.
Closure Date:
2 We recommended the Director, Ralph H. Johnson VAMC, ensure that consults that were not acted on within 7 days can be tracked and managed in accordance with national policy.
Closure Date:
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| 15-02278-415 | Review of Alleged Misuse of VA Funds at the VA Pittsburgh Healthcare System | Audit | ||
1 We recommended the Veterans Integrated Service Network 4 Director ensure the VA Pittsburgh Healthcare System conduct annual reviews to ensure its resident meal plans are appropriate and supported by adequate documentation.
Closure Date:
2 We recommended the Veterans Integrated Service Network 4 Director ensure the VA Pittsburgh Healthcare System evaluate purchasing meals internally from the Veterans Canteen Service as an alternative to commercial sources.
Closure Date:
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| 15-04247-111 | Healthcare Inspection – Review of Antimicrobial Stewardship Programs in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement procedures to ensure that facilities comply with Veterans Health Administration Directive 1031 requirements, including the completion of annual evaluations, designation of provider and pharmacy champions, staff education, and the provision of adequate dedicated staffing and resources.
Closure Date:
2 We recommended that the Under Secretary for Health require that Veterans Health Administration facilities track and generate clinical outcome reports on antibiotic use.
Closure Date:
3 We recommended that the Under Secretary for Health consider implementing standardized tools and definitions for antimicrobial stewardship data and a uniform reporting system to permit analysis of comparable information over time.
Closure Date:
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| 14-03434-102 | Healthcare Inspection – Review of Complaints Regarding Mental Health Services Clinical and Administrative Processes, VA St. Louis Health Care System, St. Louis, Missouri | Hotline Healthcare Inspection | ||
1 We recommended that the Acting System Director ensure that Mental Health Service reviews daily psychiatric patient care activity and determine if productivity is consistent with work relative value unit-based productivity and meets reasonable expectations for number of patients treated.
2 We recommended that the Acting System Director ensure that staff psychiatrists’ scheduling grids are consistent with expected patient care activity.
3 We recommended that the Acting System Director ensure that processes be strengthened to review and rectify psychiatry staff’s Current Procedural Terminology coding errors.
Closure Date:
4 We recommended that the Acting System Director ensure that processes be strengthened for timely response to mental health clinic group treatment patient referrals.
Closure Date:
5 We recommended that the Acting System Director ensure that mental health staff adequately assess and document treatment needs and follow-up arrangements for unscheduled (walk-in) patients.
Closure Date:
6 We recommended that the Acting System Director ensure that facsimile machine numbers provided to referral sources are functional and appropriately located for timely response.
7 We recommended that the Acting System Director strengthen the Compensation and Pension evaluation documentation processes to enhance accuracy of information.
8 We recommended that the Acting System Director ensure that processes be strengthened to include patients in treatment planning when they are transferred to another clinic.
Closure Date:
9 We recommended that the Acting System Director ensure that peer reviews are inclusive of all relevant clinicians and timely and that managers take appropriate follow-up actions, if indicated.
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| 16-00790-417 | Review of Alleged Wasted Funds at Consolidated Patient Account Centers for Windows Enterprise Licenses | Audit | ||
1 We recommended the Assistant Secretary for Information and Technology implement a policy to ensure cost-effective utilization of information technology equipment, installed software, and services and ensure coordination of acquisitions with affected VA organizations. This will help ensure VA’s operating framework and organizational needs are considered prior to acquisitions.
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| 16-03330-91 | Administrative Investigation - Conduct Prejudicial to the Government and Misuse of Position in the VA Office of General Counsel, Washington, DC | Administrative Investigation | ||
1 We recommend that VA’s General Counsel confer with the Office of Human Resources to determine the appropriate administrative action to take, if any, against Mr. Burch.
2 We recommend that VA’s General Counsel conduct a review of the CFBNP Steering Committee charter, membership, and activities, to determine whether members of the committee have engaged in a conflict of interest, or created the appearance of one, through the members’ association with non-Governmental Organizations, as defined in VA Directive 0008, or otherwise, and take the appropriate corrective action.
Closure Date:
3 We recommend that VA’s General Counsel extend the “covered positions” requirement for filing of Confidential Financial Disclosure Reports under 5 C.F.R. § 2634.904(a) to all attorneys employed by VA.
Closure Date:
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| 15-05180-75 | Healthcare Inspection – Mental Health-Related Concerns, W. G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement strategies to enhance communication and coordination across clinical areas for patients with High Risk for Suicide Patient Record Flags.
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| 14-02890-72 | Review of Alleged Wait-Time Manipulation at VHA's Southern Arizona VA Health Care System | Audit | ||
1 We recommended the VA Desert Pacific Healthcare Network Director review the training records of all SAVAHCS schedulers to ensure their training is compliant with Veterans Health Administration scheduling policy.
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2 We recommended the VA Desert Pacific Healthcare Network Director ensure that SAVAHCS schedulers comply with current VHA policy regarding scheduling policies and practices.
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3 We recommended the VA Desert Pacific Healthcare Network Director perform an administrative investigation to determine who directed former Business Service Line officials to create and use training materials that did not comply with VA scheduling policy and take appropriate disciplinary action for any individuals involved.
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15039