Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-04274-418 | Healthcare Inspection – Operating Room Reusable Medical Equipment and Sterile Processing Service Concerns, VA New York Harbor Healthcare System, New York, New York | Hotline Healthcare Inspection | ||
1 We recommended that the System Director charter a team to evaluate the facility's entire process involving reusable medical equipment in accordance with applicable guidelines, integrate reviews' recommendations, and develop an overarching reusable medical equipment management plan.
Closure Date:
2 We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable national and local policies and guidelines for the reprocessing of reusable medical equipment and the preparation of trays and instrument lists.
Closure Date:
3 We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable guidelines to record daily temperature and humidity levels in Sterile Processing Service areas and act upon and document actions when temperature and humidity levels are out of range.
Closure Date:
4 We recommended that the System Director ensure that an ergonomic assessment be made of the physical access and weight of items stored in the operating room Sterile Processing Service storage area and ensure staff safety and compliance with applicable Occupational Safety and Health Administration standards.
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5 We recommended that the System Director ensure training of operating room staff in proper handling of sterile packages and establish a formal process to track and trend issues with packages.
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6 We recommended that the System Director ensure adequate staffing to manage the operational requirements of Sterile Processing Service.
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7 We recommended that the System Director ensure that the operating room and Sterile Processing Service staff implement a reusable medical equipment quality control program consistent with Veteran Health Administration guidelines.
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8 We recommended that the System Director implement measures to improve collaboration and communication within and between operating room and Sterile Processing Service staff.
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| 15-02707-277 | Review of VBA’s Special Monthly Compensation Housebound Benefits | Audit | ||
1 We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to prevent staff from completing a decision without considering potential eligibility to statutory housebound benefits any time a veteran has a single 100 percent evaluation.
Closure Date:
2 We recommended the then Acting Under Secretary for Benefits conduct a review of all veterans being paid compensation at the housebound rate with a combined evaluation of 90 percent or less and provide certification of completion of the review to the Office of Inspector General.
Closure Date:
3 We recommended the then Acting Under Secretary for Benefits establish a plan to conduct periodic reviews of high-risk cases in which housebound benefits are being paid.
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4 We recommended the then Acting Under Secretary for Benefits implement a plan to provide all decision-makers the updated special monthly compensation training and monitor the effectiveness of the training.
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5 We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to ensure staff discontinue temporary housebound benefits when the criteria are no longer met.
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6 We recommended the then Acting Under Secretary for Benefits remind staff of the requirements to use the Special Monthly Compensation Calculator in all special monthly compensation cases and include the results in the file, and implement a plan to ensure compliance.
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7 We recommended the then Acting Under Secretary for Benefits clarify the meaning of the term substantially confined for housebound in-fact benefits.
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| 16-00351-453 | OIG Determination of VHA Occupational Staffing Shortages | National Healthcare Review | ||
1 We restated our previous recommendation that the Under Secretary for Health ensure that the Veterans Health Administration develops staffing models for critical need occupations, and we further recommend that the Veterans Health Administration sets forth milestones and a timetable for further critical need occupations’ staffing model development, piloting, and implementation.
Closure Date:
2 We restated our previous recommendation that the Under Secretary for Health review data on regrettable losses and consider implementing measures to reduce such losses.
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3 We recommended that the Under Secretary for Health consider incorporating data that predicts changes in veteran demand for health care into its staffing model.
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4 We recommended that the Under Secretary for Health assess 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.
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| 16-03960-428 | Combined Assessment Program Summary Report – Evaluation of Advance Directives in Veterans Health Administration Facilities | 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 employees consistently ask inpatients whether they want to discuss advance directives and that facility 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 when inpatients request a discussion about advance directives, clinicians consistently document that the discussion occurred using only the two Veterans Health Administration standardized note titles for advance directive discussions and that facility managers monitor compliance.
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| 15-00018-349 | Healthcare Inspection – Lack of Follow-Up Care for Positive Colorectal Cancer Screening, New Mexico VA Health Care System, Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that all patients who experienced delays in notifications of positive fecal immunochemical tests are assessed to determine if appropriate follow-up care was rendered and whether the delays adversely affected the patients¿ clinical outcomes.
Closure Date:
2 We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) regarding the care of the four patients described in this report and any additional patients identified in further review who may have been adversely affected, to determine the appropriate action to take, if any.
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3 We recommended that the Facility Director ensure that providers communicate positive colorectal cancer screening results to patients and document notifications in electronic health records according to Veterans Health Administration test notification policy.
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4 We recommended that the Facility Director ensure that processes are in place to monitor providers’ compliance with Veterans Health Administration colorectal cancer screening policy.
Closure Date:
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| 15-01396-525 | Review of VA’s Award of the PC3 Contracts | Audit | ||
1 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure sufficient oversight on all high-dollar value and complex acquisitions to prevent violations of acquisition regulations and VA policies.
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2 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure critical planning actions—requirements development, market research, and independent government cost estimates are performed and provided to contracting officers, prior to developing requests for proposals.
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3 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) obtain pricing analysis and technical assistance, to ensure quality products and services are procured at fair and reasonable contract prices.
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4 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) enforce compliance with the VA policy to document all required acquisition decisions in the Electronic Contract Management System.
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| 15-05328-373 | Healthcare Inspection – Colorectal Cancer Screening Practices, Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the selection of a colorectalcancer screening method is based on a shared decision-making process between apatient and his/her provider and that the patient‘s preference is honored.
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2 We recommended that the Facility Director define and communicate current localprocesses for obtaining screening colonoscopies.
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| 15-04655-347 | Healthcare Inspection – Summarization of Select Aspects of the VA Pacific Islands Health Care System, Honolulu, Hawaii | Hotline Healthcare Inspection | ||
1 We recommended that the VA Pacific Islands Health Care System Director continue efforts to enhance the availability of, and access to, a comprehensive network of care and services.
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| 15-03706-330 | Review of the Replacement of the Denver Medical Center, Eastern Colorado Health Care System | Audit | ||
1 We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction ensure required reconciliations of cost estimates be performed prior to releasing construction design documents for all major construction projects.
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2 We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction provide sufficient, adequately trained and experienced staff to ensure appropriate oversight is provided over all phases for future major construction projects.
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3 We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction establish policies and procedures to ensure disputes are resolved before proceeding with projects when actual cost and schedule milestones exceed established planned thresholds.
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4 We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction implement mechanisms to ensure that adequate acquisition plans for major construction projects are completed at each appropriate acquisition stage.
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5 We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction ensure adequate controls are implemented and monitored to verify change requests are processed timely.
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| 15-02776-240 | Review of VA’s Alleged Improper Termination of the e Learning Task Order | Audit | ||
1 We recommended the Deputy Assistant Secretary for Acquisition and Logistics implement a mechanism to ensure proper coordination between the Veterans Affairs Acquisition Academy and Office of Logistics and Supply Chain Management when developing logistics training.
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15039