Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-03063-511 | OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health ensure that the Veterans Health Administration further develops staffing models for critical need occupations.
Closure Date:
2 We recommended that the Under Secretary for Health review the data on regrettable losses in this report and Veterans Integrated Service Network Workforce Succession Strategic Plans and, if appropriate, consider implementing measures to reduce such losses.
Closure Date:
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| 15-00158-499 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Durham VA Medical Center, Durham, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that review of the hazardous materials inventory occurs twice within a 12-month period at the Raleigh II CBOC.
2 We recommended that the staff at the Raleigh II CBOC participate in scheduled emergency management training and exercises.
3 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
4 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
5 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
6 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
7 We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by local policy.
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| 15-02397-494 | Review of VHA’s Alleged Mishandling of Ophthalmology Consults at the Oklahoma City VAMC | Audit | ||
1 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure patients affected by inappropriately discontinued ophthalmology consults receive the necessary eye care.
Closure Date:
2 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center initiate a review of discontinued teleretinal imaging consults and take action to provide eye care when necessary.
Closure Date:
3 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that guidance and responsibilities for making referrals on discontinued and cancelled consults is well-defined and formalized into policy.
Closure Date:
4 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that staff responsible for initiating and processing consults are properly trained on all applicable guidance and policies.
Closure Date:
5 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that all referring providers with electronic notifications responsibility receive adequate training.
Closure Date:
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| 15-00606-495 | Combined Assessment Program Review of the Battle Creek VA Medical Center, Battle Creek, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that credentialing and privileging folders do not contain non-allowed information.
2 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
3 We recommended that employees secure medication carts when not in use and that facility managers monitor compliance.
4 We recommended that facility managers maintain auditory privacy in all intake/exam areas and monitor compliance.
5 We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
6 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
7 We recommended that facility managers revise the Radiology Service computed tomography quality assurance guideline to include radiologist review of appropriateness of computed tomography orders and specification of protocol prior to scans.
8 We recommended that facility managers comply with Veterans Health Administration directive requirements for exempted facilities, or if facility managers plan emergency intubation responses with onsite employees, they comply with Veterans Health Administration requirements for non-exempted facilities.
Closure Date:
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| 15-01381-437 | Inspection of VA Regional Office Phoenix, Arizona | Audit | ||
1 We recommended the Phoenix VA Regional Office Director conduct a review of the 325 temporary 100 percent disability evaluations remaining from their inspection universe as of December 17, 2014, and take appropriate action.
Closure Date:
2 We recommended the Phoenix VA Regional Office Director ensure frequent refresher training for processing higher levels of special monthly compensation and ancillary benefits claims.
Closure Date:
3 We recommended the Phoenix VA Regional Office Director implement a written plan to ensure oversight and prioritization of benefits reduction cases and related hearings.
Closure Date:
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| 15-00156-490 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of San Francisco VA Health Care System, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that hand hygiene compliance is monitored at the San Francisco VA Clinic and reported to the Infection Control Committee.
Closure Date:
2 We recommended that San Francisco VA Clinic staff store medical waste in a secure location.
Closure Date:
3 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
4 We recommended that clinic staff ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
Closure Date:
5 We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 13-03922-453 | Audit of Fiduciary Program Controls Addressing Beneficiary Fund Misuse | Audit | ||
1 We recommended the Under Secretary for Benefits revise policy to require timely removal of a fiduciary from all assigned beneficiaries when an individual case of misuse has been determined.
Closure Date:
2 We recommended the Under Secretary for Benefits retroactively establish debts for all fiduciaries who VBA determined misused beneficiary funds during calendar year 2013.
Closure Date:
3 We recommended the Under Secretary for Benefits revise policy to include clear timeliness standards from the time the hubs determine misuse occurred to the time Pension and Fiduciary Service completes the negligence determination.
Closure Date:
4 We recommended the Under Secretary for Benefits ensure the processing of all misuse actions are incorporated into quality reviews of Fiduciary Program operations.
Closure Date:
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| 15-00452-411 | Inspection of VA Regional Office, Winston-Salem, North Carolina | Audit | ||
1 We recommended the Winston-Salem VA Regional Office Director conduct a review of the 597 temporary 100 percent disability evaluations remaining from our universe as of October 8, 2014, and take appropriate actions.
Closure Date:
2 We recommended the Winston-Salem VA Regional Office Director develop and implement a plan to ensure claims processing staff receive additional training on required actions relating to required medical reexaminations.
Closure Date:
3 We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure staff receive refresher training on processing higher-level special monthly compensation claims.
Closure Date:
4 We recommended the Winston-Salem 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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| 15-01290-435 | Inspection of VA Regional Office Wichita, Kansas | Audit | ||
1 We recommended the Wichita VA Regional Office Director conduct a review of the 130 temporary 100 percent disability evaluations remaining from our inspection universe as of December 10, 2014, and take appropriate actions.
Closure Date:
2 We recommended the Wichita VA Regional Office Director implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
Closure Date:
3 We recommended the Wichita 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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| 15-00604-488 | Combined Assessment Program Review of the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
Closure Date:
2 We recommended that the facility document evacuation sled training in the Talent Management System.
Closure Date:
3 We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users and that facility managers monitor compliance.
Closure Date:
4 We recommended that facility managers ensure post-anesthesia care competency assessment is completed for critical care nurses on the intensive care units.
Closure Date:
5 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency includes review of clinician-specific data and all required elements and that facility managers monitor compliance.
Closure Date:
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15039