Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-01860-502 | Inspection of VA Regional Office Sioux Falls, South Dakota | Review | ||
1 We recommended the Sioux Falls VA Regional Office Director conduct a review of the 22 temporary 100 percent disability evaluations remaining from their inspection universe as of February 11, 2015, and take appropriate action.
Closure Date:
2 We recommended the Sioux Falls VA Regional Office Director implement a plan to improve the effectiveness of the second-signature review process for special monthly compensation and ancillary benefits claims.
Closure Date:
3 We recommended the Sioux Falls VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Closure Date:
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| 15-00170-517 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Robley Rex VA Medical Center, Louisville, Kentucky | Comprehensive Healthcare Inspection Program | ||
1 We recommended that patient-identifiable information on laboratory specimens is secured during transport from the Newburg VA Clinic to the Robley Rex VA Medical Center.
Closure Date:
2 We recommended that staff protect and secure patient-identifiable information at the Newburg VA Clinic.
Closure Date:
3 We recommended that clinic Registered Nurse Care Managers receive motivational interviewing within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
6 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by VHA and local policy and that compliance is monitored.
Closure Date:
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| 13-00690-455 | Follow-up Review of VA’s Veterans Benefits Management System | Audit | ||
1 We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, implement improved cost controls and stabilize Veterans Benefits Management System functionality requirements for the remainder of planned system development to restrict further cost increases.
Closure Date:
2 We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, perform a formal budget versus cost analysis to identify actual costs expended in support of the Veterans Benefits Management System development effort.
Closure Date:
3 We recommended the Executive in Charge for the Office of Information and Technology perform market analyses on all future Space and Naval Warfare Systems Command Atlantic task orders to determine whether the continued use of the interagency agreements is in the best interest of the Department.
Closure Date:
4 We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, establish a clear strategy and plan to decommission legacy systems, eliminate redundant systems operations, and reduce system maintenance costs.
Closure Date:
5 We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, fully develop and implement Veterans Benefits Management System electronic workflow and workload brokering functionality to facilitate more efficient claims processing.
Closure Date:
6 We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, provide adequate training with each Veterans Benefits Management System release to ensure VA Regional Office users fully benefit from the enhanced functionality provided.
Closure Date:
7 We recommended the Executive in Charge for the Office of Information and Technology implement an improved Veterans Benefits Management System network infrastructure to mitigate single points of failure and reduce the network performance issues across the enterprise.
Closure Date:
8 We recommended the Executive in Charge for the Office of Information and Technology, in conjunction with the Under Secretary for Benefits, develop sufficient Veterans Benefits Management System performance metrics to demonstrate the system is improving VA¿s ability to efficiently process claims as compared to legacy practices.
Closure Date:
9 We recommended the Executive in Charge for the Office of Information and Technology minimize the use of manual requirements tracking processes and maximize the use of automated application lifecycle management tools to manage requirements traceability in accordance with industry best practices.
Closure Date:
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| 15-00615-513 | Combined Assessment Program Review of the Durham VA Medical Center, Durham, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group meet monthly.
Closure Date:
2 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
3 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility designate a clinical subject matter expert to oversee emergency airway management.
Closure Date:
5 We recommended that the facility ensure clinicians designated for out of operating room airway management coverage have current scopes of practice and documentation of all required elements and that facility managers monitor compliance.
Closure Date:
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| 15-00399-410 | Inspection of VA Regional Office San Diego, California | Audit | ||
1 We recommended the San Diego VA Regional Office Director develop and implement a plan to ensure staff take timely actions on reminder notifications to request medical reexaminations.
Closure Date:
2 We recommended the San Diego VA Regional Office Director conduct a review of the 388 temporary 100 percent disability evaluations remaining from our inspection universe as of October 17, 2014, and take appropriate action.
Closure Date:
3 We recommended the San Diego VA Regional Office Director ensure staff receive refresher training on proper evaluation of special monthly compensation and ancillary benefits claims and implement plans to ensure the effectiveness of that training.
Closure Date:
4 We recommended the San Diego VA Regional Office Director develop and implement a plan to increase the effectiveness of the station's second-signature process for cases with special monthly compensation and ancillary benefits.
Closure Date:
5 We recommended the San Diego VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-02706-485 | Inspection of VA Regional Office Fort Harrison, Montana | Review | ||
1 We recommended the Fort Harrison VA Regional Office Director conduct a review of the 79 temporary 100 percent disability evaluations remaining from our inspection universe as of March 10, 2015, and take appropriate action.
Closure Date:
2 We recommended the Fort Harrison VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-02614-434 | Inspection of VA Regional Office Lincoln, Nebraska | Review | ||
1 We recommended the Lincoln VA Regional Office Director conduct a review of the 81 temporary 100 percent disability evaluations remaining from our inspection universe as of March 5, 2015, and take appropriate action.
2 We recommended the Lincoln VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
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| 14-01792-510 | Review of Alleged Mismanagement at the Health Eligibility Center | Audit | ||
1 We recommended the Under Secretary for Health provide guidance concerning how long applications may remain pending before reaching a final determination.
Closure Date:
2 We recommended the Under Secretary for Health assign an accountable official responsible to implement a plan to correct current data integrity issues in the Enrollment System.
Closure Date:
3 We recommended the Under Secretary for Health develop and execute a project management plan to ensure that Enrollment System data are fully evaluated and properly categorized.
Closure Date:
4 We recommended the Under Secretary for Health implement controls to ensure that future enrollment data are accurate and reliable before being entered in the Enrollment System.
Closure Date:
5 We recommended the Under Secretary for Health implement effective policies and procedures to accurately and timely identify deceased individuals with records in the Enrollment System and record their changed status in the system.
Closure Date:
6 We recommended the Under Secretary for Health establish appropriate policies and procedures to ensure Health Eligibility Center workload data are not deleted or changed without appropriate management review, approval, and audit trails.
Closure Date:
7 We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to Health Eligibility Center workload data are based upon specific job duties and the need to know.
Closure Date:
8 We recommended the Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the first three allegations, determine if administrative action should be taken against any senior Veterans Health Administration officials involved, and ensure that appropriate action is taken.
Closure Date:
9 We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
Closure Date:
10 We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
Closure Date:
11 We recommended that the Assistant Secretary for Information and Technology develop a monthly schedule to test whether Health Eligibility Center workload data are backed up properly and to provide the results of such testing to the Chief Business Office.
Closure Date:
12 We recommended the Assistant Secretary for Information and Technology confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the lack of controls over the Workload Reporting and Productivity tool, determine if administrative action should be taken against any senior Office of Information Technology officials involved, and ensure that appropriate action is taken.
Closure Date:
13 We recommended the Under Secretary for Health perform monthly comparisons between Workload Reporting and Productivity reports and enrollment records to ensure the timely processing of applications and related documents.
Closure Date:
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| 14-03531-402 | Healthcare Inspection – Alleged Delayed Mental Health Treatment and Other Care Issues, Kansas City VA Medical Center, Kansas City, MO | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health review relevant inpatient program occupancy rates and wait times system-wide and determine whether additional guidance to facilities is needed to help ensure that the number of patients served through those programs is optimized.
Closure Date:
2 We recommended that the Facility Director ensure that processes be strengthened to ensure appropriate follow through on consults that are cancelled for administrative reasons.
Closure Date:
3 We recommended that the Facility Director ensure that Emergency Department providers fully evaluate patients with abnormal findings and make those evaluations readily accessible to other providers.
Closure Date:
4 We recommended that the Facility Director ensure that patients are evaluated and referred for treatment for certain health concerns if exhibited by patients presenting to the Emergency Department, when appropriate.
Closure Date:
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| 15-00154-500 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Maine Healthcare System, Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
6 We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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15039