Recommendations
2059
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-04132-48 | Comprehensive Healthcare Inspection of the Tomah VA Medical Center in Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by conducting Ongoing Professional Practice Evaluations on a regular basis.
Closure Date:
2 The Medical Center Director ensures the Safety and Occupational Health Specialist or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.
Closure Date:
3 The Medical Center Director ensures staff monitor and document VA police response times to panic alarm testing in the Acute Inpatient Mental Health Unit at least quarterly.
Closure Date:
4 The Medical Center Director ensures the Suicide Prevention Coordinator conducts a minimum of five outreach activities each month.
Closure Date:
5 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health and quality management leaders.
Closure Date:
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| 23-00093-51 | Comprehensive Healthcare Inspection of the Wilmington VA Medical Center in Delaware | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff track deficiencies identified during comprehensive environment of care inspections through resolution.
Closure Date:
2 The Director ensures staff maintain a safe and clean environment.
Closure Date:
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| 21-01488-44 | Veterans Health Administration Needs More Written Guidance to Better Manage Inpatient Management of Alcohol Withdrawal | National Healthcare Review | ||
1 The Under Secretary for Health consider identifying a national program office to be responsible for oversight of alcohol withdrawal management across inpatient settings.
Closure Date:
2 The Under Secretary for Health ensures the identified national program office responsible for oversight of alcohol withdrawal management consider requiring the development and implementation of written guidance for the management of alcohol withdrawal across all inpatient settings, to include: (a) expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; (b) expected actions of nurses to communicate with prescribers based on patients’ changes in symptoms or alcohol withdrawal severity and when that communication should be followed by a prescribers face-to-face evaluation of a patient; (c) expectations for the evaluation of co-occurring conditions, expert consultation, and pharmacotherapy approaches; and (d) expectations for the collection and monitoring of outcome data for inpatient management of alcohol withdrawal at the national and healthcare system level.
3 The Under Secretary for Health consider the implementation of training for inpatient staff on the administration of standardized alcohol withdrawal severity scales.
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| 22-02294-42 | Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates a review of the surgeon’s eligibility to participate in VA’s Community Care Network given Optum’s lack of documentation of their review of the surgeon’s credentialing file and takes action, as indicated.
Closure Date:
2 The Under Secretary for Health reviews community care network contracts and considers modifying contracts to ensure that voluntary relinquishments and surrenders of licenses for disciplinary reasons are disqualifying for participation in VA’s Community Care Network consistent with the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.
Closure Date:
3 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures Optum’s sufficient review and discussion of community care network providers’adverse credentialing files and monitors for compliance.
Closure Date:
4 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum documents community care network provider credentialing decisions asrequired and monitors for compliance.
Closure Date:
5 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum complies with community care contract provisions to provide Integrated Veteran Care with accreditation and credentialing documentation in accordance with federal privacy laws and VA’s community care network contract.
Closure Date:
6 The Office of Integrated Veteran Care Executive Director, Integrated External Networks verifies that providers identified on the 2021 Government Accountability Office list are eligible to provide care in the VA Community Care Network.
Closure Date:
7 The VA Heartland Network Director initiates a review of all community care provided by the surgeon.
Closure Date:
8 The VA Marion Health Care System Director ensures primary care and patient safety staff receive education on their responsibility for Joint Patient Safety Reporting and follow-up of patient safety events related to community care, and monitors compliance with patient safety event reporting and follow-up.
Closure Date:
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| 23-01690-31 | Without Effective Controls, Public Disability Benefits Questionnaires Continue to Pose a Significant Risk of Fraud to VA | Review | ||
1 Direct the Office of Financial Management to continue to develop a system for digitally capturing, analyzing, and monitoring public questionnaires to identify inauthentic or potentially fraudulent questionnaires and work with the Compensation Service to develop policies for reviewing and remediating any such public questionnaires identified.
Closure Date:
2 Have the Medical Disability Examination Office update the examiner certification and signature section found in public questionnaires to include that the form is being completed under the penalty of perjury and to ask examiners to list any organizations that requested they complete the examinations on the claimant’s behalf.
Closure Date:
3 Instruct the Compensation Service to provide claims processors guidance in the procedures manual on how to identify a potentially fraudulent public questionnaire, and provide the steps they should take when they suspect that a public questionnaire may be inauthentic or potentially fraudulent.
Closure Date:
4 Require the Compensation Service to inform claims processors as part of the public questionnaire review process that they have a duty to review and weigh all the evidence of record, including public questionnaires, and that they have the responsibility to assign low or no probative value if they have reason to suspect that the public questionnaire is inauthentic or potentially fraudulent.
Closure Date:
5 Direct the Veterans Benefits Administration to develop and provide training on authentication and fraud, including training related to public questionnaires, to provide claims processors with the knowledge to identify inauthentic or potentially fraudulent public questionnaires, and include what steps claims processors should take when they make that determination.
Closure Date:
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| 23-00007-45 | Comprehensive Healthcare Inspection of the Miami VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures staff complete peer reviews for unanticipated deaths occurring within 24 hours of admission.
Closure Date:
2 The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
Closure Date:
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| 22-03165-46 | Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Associate Director ensures managers maintain a safe and clean environment throughout the medical center.
Closure Date:
4 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen when it is clinically appropriate.
Closure Date:
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| 23-00004-37 | Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.
Closure Date:
2 The Chief of Staff ensures clinical staff notify the suicide prevention team if patients report suicidal or other self-directed violent behaviors that occurred in the 12 months preceding the Comprehensive Suicide Risk Evaluation.
Closure Date:
3 The Chief of Staff ensures leaders appoint one full-time suicide prevention coordinator to each community-based outpatient clinic that serves at least 10,000 unique veterans annually.
Closure Date:
4 The Chief of Staff ensures the Suicide Prevention Program Manager reports suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
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| 22-02934-208 | VA Should Validate Contractor Energy Baseline and Savings Estimates and Ensure Payments Are Legally Compliant | Audit | ||
1 Develop specific policy and procedures to ensure the contractor’s investment grade audit, which includes the contractor’s energy baseline and cost savings estimates, are witnessed and validated per Federal Energy Management Program guidelines.
Closure Date:
2 Publish criteria for payments for energy savings performance contracts to ensure compliance with federal law and Department of Energy Federal Energy Management Program guidance.
Closure Date:
3 Develop procedures to ensure contracting officer’s representatives or other contracting officer designees have independently witnessed and validated the contractor’s energy baseline and savings estimates prior to negotiating energy savings performance contracts’ guaranteed savings amounts.
Closure Date:
4 Develop oversight procedures to ensure documentation that demonstrates the contractor’s energy baseline and energy savings estimates were witnessed and validated is maintained in the official contracting records.
Closure Date:
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| 22-00410-197 | VA Needs to Conduct Seismic Evaluations on Critical and Essential Buildings to Effectively Prioritize Program Funds | Audit | ||
1 The executive director of VA’s Office of Construction and Facilities Management should confirm seismic evaluations are done for all critical and essential buildings in high and very high seismic zones immediately to ensure they meet life, safety, and occupancy performance standards
2 The executive director of the Office of Construction and Facilities Management should review the Capital Asset Inventory and work with Veterans Health Administration Office of Capital Asset Management, Veterans Integrated Service Network capital asset managers, and VA medical facility engineers to update and correct inaccurate seismic data in the Capital Asset Inventory.
Closure Date:
3 The executive director of the Office of Construction and Facilities Management should submit change requests to the Capital Asset Inventory so that critical and essential designations are visible to medical center engineers and Veterans Integrated Service Network capital asset managers.
Closure Date:
4 The executive director of the Office of Asset Enterprise Management should ensure facilities and Veterans Integrated Service Networks review critical and essential designations as part of their annual certifications of the Capital Asset Inventory.
Closure Date:
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14934