Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-02389-23 | Deficiencies in Inpatient Mental Health Suicide Risk Assessment, Mental Health Treatment Coordinator Processes, and Discharge Care Coordination | National Healthcare Review | ||
1 The Under Secretary for Health monitors inpatient mental health unit adherence to suicide risk identification processes and identifies and addresses barriers.
Closure Date:
2 The Under Secretary for Health ensures inpatient mental health unit staff complete suicide prevention safety plans as expected, and monitors compliance.
Closure Date:
3 The Under Secretary for Health clarifies requirements for facility-level written guidance regarding the processes for mental health treatment coordinator identification, assignment, and care coordination, and monitors compliance.
Closure Date:
4 The Under Secretary for Health ensures accurate and timely mental health treatment coordinator assignment, including patient centered management module entry and notification for the assigned staff and applicable patient.
Closure Date:
5 The Under Secretary for Health evaluates the effectiveness of dedicated mental health treatment coordinators in enhancing patient engagement in outpatient mental health care following discharge from an inpatient mental health unit, and takes action as appropriate.
Closure Date:
6 The Under Secretary for Health considers establishing written guidance regarding expectations for mental health unit staff to schedule patients’ post-discharge mental health care appointments.
Closure Date:
7 The Under Secretary for Health determines supportive factors that contribute to patients’ attendance at outpatient mental health appointments following discharge from an inpatient mental health unit, including self-motivation enhancement and family and friend involvement, and takes action to integrate such factors into discharge planning procedures.
Closure Date:
8 The Under Secretary for Health considers establishing a process for patient orientation to the behavioral health interdisciplinary team to facilitate patient awareness of, and accessibility to, team members, and takes action as appropriate.
Closure Date:
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| 24-00704-21 | Allegation of Underutilization of Mental Health Clinics, and Concern for Delays in Patient Care, at the Hinesville VA Clinic in Georgia | Hotline Healthcare Inspection | ||
1 The Ralph H. Johnson VA Health Care System Director ensures optimal mental health clinic utilization at the Hinesville VA Clinic.
Closure Date:
2 The Ralph H. Johnson VA Health Care System Director ensures that mental health Hinesville VA Clinic staff are using accurate current procedural terminology codes to document services provided to patients in the electronic medical record.
Closure Date:
3 The Ralph H. Johnson VA Health Care System Director confirms evaluation of administrative processes to include consult management and patient scheduling within the mental health service at the Hinesville VA Clinic and takes action as necessary to optimize patient access and experience.
Closure Date:
4 The Ralph H. Johnson VA Health Care System Director completes a review of the patients identified by the Office of Inspector General to have experienced a median wait time of at least three weeks between individual therapy sessions and takes action to resolve any patient care concerns identified during the review.
Closure Date:
5 The Ralph H. Johnson VA Health Care System Director considers evaluating the Choose My Therapy program at other system sites for clinic practice management deficiencies and takes action as appropriate.
Closure Date:
6 The Ralph H. Johnson VA Health Care System Director ensures that all patients listed in the electronic spreadsheet have received mental health follow-up care.
Closure Date:
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| 21-00524-25 | VHA Policy and Practice Support Age-Specific Osteoporosis Screening in Women | National Healthcare Review | ||
1 The Under Secretary for Health works with the Women’s Program Office to gain an understanding of barriers to osteoporosis clinical reminder use and based on results, implement action as needed.
Closure Date:
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| 24-00589-17 | Healthcare Facility Inspection of the VA Northport Healthcare System in New York | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure staff secure all medications and the supplies used to administer medications in the Emergency Department.
Closure Date:
2 The OIG recommends facility leaders confirm staff are knowledgeable about how the lobby kiosks function to assist veterans with sensory impairments.
Closure Date:
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| 24-00586-11 | Healthcare Facility Inspection of the Durham VA Health Care System in North Carolina | Healthcare Facility Inspection | ||
1 The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.
Closure Date:
2 The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.
Closure Date:
3 The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.
Closure Date:
4 The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.
Closure Date:
5 The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.
Closure Date:
6 The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.
Closure Date:
7 The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.
Closure Date:
8 The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.
Closure Date:
9 The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.
Closure Date:
10 The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.
Closure Date:
11 The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.
Closure Date:
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| 24-00118-01 | Staff Incorrectly Processed Claims When Denying Veterans’ Benefits for Presumptive Disabilities Under the PACT Act | Review | ||
1 Update VA’s Adjudication Procedures Manual on when personnel should request medical disability examinations and opinions.
Closure Date:
2 Reduce examination and medical opinion overdevelopment by establishing a plan to continue the development of examination request tools and evaluate the effectiveness of these efforts for any future enhancements.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $1,420,804
Total: $1,420,804
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| 23-03517-230 | Survivors Did Not Always Receive Accurate Retroactive Benefits for Dependency and Indemnity Compensation Claims Reopened Under the PACT Act | Review | ||
1 Correct the two errors involving prematurely denied Dependency and Indemnity Compensation claims.
Closure Date:
2 Conduct a file review of the reopened Dependency and Indemnity Compensation claims granted under the PACT Act from January 1 through August 31, 2023, and take appropriate actions to ensure monetary benefits and notification letters are accurate.
Closure Date:
3 Consider whether modifications could be made to the reevaluation request process consistent with the PACT Act and related regulations and, should this result in a policy change, consult with the VA Office of General Counsel.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $33,100,000
Total: $33,100,000
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| 23-02682-09 | Veterans Health Administration Initiated Toxic Exposure Screening as Required by the Promise to Address Comprehensive Toxics (PACT) Act but Improvements Needed in the Training Process | National Healthcare Review | ||
1 The Under Secretary for Health ensures Veterans Health Administration leaders assess reasons for noncompliance with training requirements and takes action as warranted.
Closure Date:
2 The Under Secretary for Health evaluates whether toxic exposure screening is negatively affecting primary care workload and takes action to mitigate as needed.
Closure Date:
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| 23-00547-187 | VBA Did Not Ensure Employees Sent Some Letters Using Its Package Manager Application | Review | ||
1 Implement and periodically monitor the effectiveness of a plan to provide oversight for unsent packages in the Package Manager application.
2 Implement a plan to address existing unsent packages in the Package Manager application.
Closure Date:
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| 24-01232-02 | Inspection of Information Security at the Health Eligibility Center in Atlanta, Georgia | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure all vulnerabilities are identified and that plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
2 Implement a more effective system life-cycle process to ensure network devices are running authorized software and operating systems that are configured to approved baselines and free of vulnerabilities.
Closure Date:
3 Ensure all file systems holding veteran information are encrypted in accordance with NIST and VA policy requirements.
Closure Date:
4 Maintain an accurate inventory of personnel with key access to the facility.
Closure Date:
5 Enable improved audit logging capability to monitor administrator access to sensitive information hosted on the Workload Reporting and Productivity Assessing file server.
Closure Date:
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15303