Recommendations
2106
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-02638-01 | Combined Assessment Program Review of the Chalmers P. Wylie VA Ambulatory Care Center, Columbus, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that sterile supply storage and soiled utility areas are secured at all times.
Closure Date:
2 We recommended that the facility develop instructions for inspections of automated dispensing machines.
Closure Date:
3 We recommended that processes be strengthened to ensure that quarterly trend reports include problematic trends and potential areas for improvement.
Closure Date:
4 We recommended that processes be strengthened to ensure that CS inspectors receive annual CS updates and/or refresher training.
Closure Date:
5 We recommended that processes be strengthened to ensure that CS inspectors consistently verify the number of prescription pads and that compliance be monitored.
Closure Date:
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| 13-00026-352 | Community Based Outpatient Clinic Reviews at VA Western New York Healthcare System, Buffalo, NY | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a process is established to ensure that the ordering provider or surrogate is notified of normal cervical cancer screening results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccine administration elements and that compliance is monitored.
Closure Date:
4 We recommended that the Executive Committee of the Medical Staff grants privileges consistent with the services provided at the Lackawanna and Niagara Falls CBOCs.
Closure Date:
5 We recommended that laboratory specimens are secured during transport from the Lackawanna and Niagara Falls CBOCs to the parent facility to prevent the disclosure of patients PII.
Closure Date:
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| 13-00505-348 | Healthcare Inspection – Emergency Department Patient Deaths’ Memphis VAMC, Memphis, Tennessee | Hotline Healthcare Inspection | ||
1 We recommended that Facility Director confer with Regional Counsel for possible disclosure to the surviving family member(s) of Patient 3.
Closure Date:
2 We recommended that the Facility Director ensure that root cause analysis action plans are documented, monitored, and completed promptly.
Closure Date:
3 We recommended that the Facility Director ensure that patients are appropriately monitored in all emergency department rooms.
Closure Date:
4 We recommended that the Facility Director ensure that unit-specific competency assessments are completed for emergency department nursing staff.
Closure Date:
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| 12-04046-307 | Review of VA's Management of Health Care Center Leases | Audit | ||
1 We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, establish adequate guidance for the procurement oflarge-scale build-to-lease facilities.
2 We recommended the Principal Executive Director, Office ofAcquisition, Logistics, and Construction, in coordination with the UnderSecretary for Health, provide realistic and justifiable timelines for award,construction, and activation of the Health Care Center leases.
3 We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, ensure supporting analyses and key decisions regarding theHealth Care Center leases are supported and documented.
4 We recommended the Under Secretary for Health, in coordination withthe Principal Executive Director, Office of Acquisition, Logistics, andConstruction, establish central cost tracking to ensure transparency andaccurate reporting on Health Care Center expenditures.
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| 13-00090-346 | Evaluation of VHA Community Based Outpatient Clinics Fiscal Year 2012 | Comprehensive Healthcare Inspection Program | ||
1 Ensure that CBOC clinicians document foot care education provided to diabetic patients in the electronic health record.
Closure Date:
2 Ensure that CBOC clinicians perform risk assessments and document risk levels for diabetic patients in the electronic health record.
Closure Date:
3 Ensure that CBOC clinicians document referrals for preventative foot care, including foot wear, as clinically indicated, for patients with diabetes in the electronic health record.
Closure Date:
4 Ensure that CBOC managers establish a process to consistently link breast imaging and mammography results to the appropriate radiology mammogram or breast study order for all fee basis and contract patients.
Closure Date:
5 Ensure that CBOC managers establish a process to notify patients of normal mammogram results within the allotted timeframe and that notification is documented in the electronic health record.
Closure Date:
6 Ensure that service chiefs¿ documentation in VetPro reflects documents reviewed and the rationale for privileging or re-privileging CBOC providers.
Closure Date:
7 Ensure that facility Directors grant privileges consistent with the services provided at the CBOCs.
Closure Date:
8 Ensure that adequate resources and controls are in place to address deficiencies in the invoice validation process and to reduce the risk of overpayments.
Closure Date:
9 Ensure that the oversight of the contract acquisition process is compliant with VA Directives, including a thorough pre-award review and interim contract authority prior to contract approval.
Closure Date:
10 Ensure that all new CBOCs undergo the required contract approval processes prior to initiating operations.
Closure Date:
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| 11-00330-338 | Audit of Selected VHA Non-Institutional Purchased Home Care Services | Audit | ||
1 We recommended the Under Secretary for Health ensure VA medical facilities apply standardized eligibility criteria and ensure purchased home care review processes are not improperly used to limit access to purchase home care services.
Closure Date:
2 We recommended the Under Secretary for Health ensure VA medical facilities maintain waiting lists for purchased home care services and assess eligible veterans¿ unmet needs for services.
Closure Date:
3 We recommended the Under Secretary for Health correct eligibility information in VA's Veterans' Health Care Benefits Overview booklet and on the Office of Geriatrics and Extended Care's Web site to be consistent with VHA policy and indicate veterans do not have to be homebound to be eligible for purchased skilled care services.
Closure Date:
4 We recommended the Under Secretary for Health strengthen non-institutional care program oversight to monitor budgeted and expended funding for purchased home care services and ensure average daily census performance monitoring data is accurate, reliable, and transparent.
Closure Date:
5 We recommended the Under Secretary for Health implement effective performance measures for purchased home care services to ensure VA medical facilities do not improperly limit access to services.
Closure Date:
6 We recommended the Under Secretary for Health implement management controls to ensure VA medical facilities adhere to the Veterans Health Administration's requirements related to the identification and management of ineligible and high-risk purchased home care agencies.
Closure Date:
7 We recommended the Under Secretary for Health clarify the Veterans Health Administration's purchased home care policies and provide appropriate VA medical facility staff training on the proper use of eligible purchased home care agencies, exemptions, and the monitoring of high-risk agencies.
Closure Date:
8 We recommended the Under Secretary for Health establish effective controls and monitors to ensure providers properly document orders and fee staff properly verifies the appropriateness of the services in accordance with VA fee policies before they pay for purchased home care services.
Closure Date:
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| 11-01653-300 | Review of VHA's Management of Travel, Duty Stations, Salaries and Funds in the Procurement and Logistics Office | Audit | ||
1 We recommend the Chief Procurement and Logistics Officer
establish standard operating procedures to ensure that Procurement and Logistics Office approving officials only authorize travel upon obtaining the information needed to determine if travel is necessary.
Closure Date:
2 We recommend the Chief Procurement and Logistics Officer perform an annual review of all Procurement and Logistics Office employees to ensure they have correct duty station assignments.
Closure Date:
3 We recommend the Chief Procurement and Logistics Officer take
action to recoup salary overpayments or pay underpayments for
incorrect duty station assignments, as appropriate, in accordance with VA guidance.
Closure Date:
4 We recommend the Chief Procurement and Logistics Officer provide training annually to supervisors and financial officials regarding permitted versus restricted uses of the VA Supply Fund.
Closure Date:
5 We recommend the Deputy Assistant Secretary, Office of Acquisition and Logistics, in coordination with the Chief Procurement and Logistics Officer, establish a formal agreement outlining their respective management responsibilities and permitted versus restricted uses of the VA Supply Fund.
Closure Date:
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| 13-00455-345 | Review of VA's Separately Priced Item Purchases for Training Conferences | Audit | ||
1 We recommended the Assistant Secretary for Human Resources and Administration consider discontinuing the use of assisted acquisition interagency agreements with the Office of Personnel Management for planning and conducting training conferences.
Closure Date:
2 We recommended the Assistant Secretary for Human Resources and Administration establish controls to ensure adequate visibility and oversight of separately priced items purchased through existing interagency agreements with the Office of Personnel Management, to include ensuring proposed purchases are approved in advance and determined to be for incidental items that support essential tasks developed under the interagency agreement.
Closure Date:
3 We recommended the Assistant Secretary for Human Resources and Administration ensure that VA receives and reviews invoices or receipts that support all separately priced items purchased through existing interagency agreements with the Office of Personnel Management prior to authorizing payment.
Closure Date:
4 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction update its policy to ensure a qualified individual with appropriate training in contracting is assigned to all existing interagency agreements with the Office of Personnel Management to monitor work performed on VA’s behalf.
Closure Date:
5 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction request the Office of Personnel Management review all bills associated with VA’s financial management training conferences, assess the results of the Office of Personnel Management’s review, and take steps to recover service fees paid to the prime vendor as a percentage of the cost of separately priced item purchases.
Closure Date:
6 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction assess the Office of Personnel Management’s oversight of separately priced items purchased through the interagency agreement used to fund, plan, and conduct VA’s financial management training conferences, and take steps to recover service fees paid to the Office of Personnel Management associated with inadequate oversight.
Closure Date:
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| 13-01974-337 | Combined Assessment Program Review of the Philadelphia VA Medical Center, Philadelphia, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are reported to the PSB.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode.
Closure Date:
5 We recommended that fire extinguisher signage be in place and operational in accordance with National Fire Protection Association Standards.
Closure Date:
6 We recommended that processes be strengthened to ensure that all designated hemodialysis employees receive annual bloodborne pathogens training.
Closure Date:
7 We recommended that chemicals stored on the hemodialysis unit be secured at all times and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that OR employees who perform IUS receive annual competency assessments.
Closure Date:
9 We recommended that processes be strengthened to ensure monthly inspections are completed in the inpatient pharmacy, the outpatient pharmacy, and the CLC vault and for the emergency drug cache and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person and a psychologist.
Closure Date:
11 We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
12 We recommended that the identified environmental hazards on the locked MH unit be corrected and that processes be strengthened to ensure that all environmental hazards on the locked MH units are identified and corrected.
Closure Date:
13 We recommended that processes be strengthened to ensure that all staff who work on locked inpatient MH units and MSIT members receive annual environmental hazards training.
Closure Date:
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| 12-02387-343 | Audit of VA's Technology Acquisition Center Contract Operations | Audit | ||
1 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction ensure that contracting activities can adequately justify the use of exceptions to competition requirements in the Federal Acquisition Regulation when awarding Indefinite/Delivery Indefinite Quantity task orders.
Closure Date:
2 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction require contracting activities to ensure program offices adequately document that goods and services cannot be acquired as conveniently or economically from a commercial source before awarding Interagency Acquisitions.
Closure Date:
3 We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction build in steps into the Integrated Oversight Process to hold contracting officers accountable for preventing violations of Federal Acquisition Regulation competition requirements.
Closure Date:
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15200