Recommendations
2059
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-02739-210 | Significant Deficiencies Found in VA’s Denver Logistics Center Inventory Management Operations and Systems | Audit | ||
1 Implement oversight, monitoring, and quality assurance mechanisms that routinely ensure all goods received by the Denver Logistics Center are accurately and promptly recorded in the inventory management system at the time of receipt.
Closure Date:
2 Properly record all apnea stock in the inventory management system.
Closure Date:
3 Ensure Denver Logistics Center management routinely assess the appropriateness of manual adjustments to the inventory system and document the findings and causes, review trends in error codes, and develop action plans to minimize inaccuracies in future physical counts.
Closure Date:
4 Strengthen controls over inventory adjustments to ensure the accountable officer or designee reviews and approves supply variances above an established threshold.
Closure Date:
5 Establish and implement policy that clearly defines roles and responsibilities for Denver Logistics Center logistics and warehouse employees, separates duties to avoid conflicts of interest, and enhances the quality assurance function.
Closure Date:
6 Establish and implement formal policies and procedures specific for inventory management operations at the Denver Logistics Center, to include cycle counts, regular inventory audits, adjustments and forecasting demand, safety levels, reordering, and tools to allow for automated scanning.
Closure Date:
7 Develop and deliver formal training to logistics and warehouse staff on inventory management policies, procedures, and tools.
Closure Date:
8 Implement routine reporting of all Denver Logistics Center inventory adjustments to the National Acquisition Center and the Office of Acquisition, Logistics, and Construction.
Closure Date:
9 Ensure the Denver Logistics Center staff complete reports of survey for adjustments to inventory in accordance with VA logistics management policy, and communicate such information to the National Acquisition Center.
10 Address the physical security issues identified and develop, implement, and provide initial and recurring training and guidance to Denver Logistics Center’s logistics, distribution, and contract staff on proper physical security controls and procedures, including the proper disposal of personally identifiable information.
Closure Date:
11 Conduct an independent, comprehensive, and multiyear financial audit that includes wall-to-wall inventory assessments of the Denver Logistics Center.
Closure Date:
12 Transfer the stewardship and responsibility for Denver Logistics Center systems to the Office of Information and Technology.
Closure Date:
13 In collaboration with the Office of Information and Technology, establish information system controls for user access, segregation of duties designations, permission access, and privilege access for the inventory management systems and data.
Closure Date:
14 Establish and perform routine reviews of the access levels for users with direct access to the inventory management systems and ensure that access is limited to those who have a defined business purpose.
15 In collaboration with the Office of Information and Technology, ensure the Denver Logistics Center meets physical access, security, and contingency planning requirements for its information management systems.
16 Establish a connection for Denver Logistics Center inventory data to VA’s Corporate Data Warehouse.
17 In collaboration with the Office of Information and Technology, ensure the information technology system application does not bypass internal control restrictions, has a complete audit trail, and does not introduce errors in the information system.
Closure Date:
18 Ensure the Denver Logistics Center develops and maintains comprehensive documentation of the information system to support operations and train information resource management staff.
19 Ensure security documentation accurately supports the proper controls are implemented, tested, and representative of the system security.
Closure Date:
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| 21-03102-201 | The Office of Integrated Veteran Care Needs to Improve Community Dialysis Oversight and Develop a Strategy to Align Future Contracts with the MISSION Act | Audit | ||
1 Clarify guidance to ensure it includes local dialysis contract options and specifically defines when they should be used.
Closure Date:
2 Establish roles and responsibilities to ensure dialysis coordinators follow required procedures when referring veterans to dialysis care in the community.
Closure Date:
3 Develop and implement a plan to regularly examine and validate dialysis provider information in the Provider Profile Management System for accuracy and completeness.
Closure Date:
4 Develop and implement a strategy to ensure that any new dialysis service contracts follow the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 payment rate requirements.
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| 21-01445-30 | Greater Compliance with Policies Needed Related to the Management of Emergent Care for Patients Presenting with Acute Sexual Assault | National Healthcare Review | ||
1 The Under Secretary for Health makes certain the Veterans Health Administration complies with requirements that all acute sexual assault victim-survivors are offered prophylaxis for sexually transmitted infection when clinically indicated and monitors compliance.
Closure Date:
2 The Under Secretary for Health verifies compliance with Veterans Health Administration requirements that all acute sexual assault victim-survivors are offered prophylaxis for pregnancy when clinically indicated and monitors compliance.
3 The Under Secretary for Health ensures all sexual assault victim-survivors are offered mental health resources, either directly through Veterans Health Administration or through the community and monitors compliance.
4 The Under Secretary for Health ensures compliance with Veterans Health Administration requirements for documentation of signature informed consent for forensic examinations conducted by staff at Veterans Health Administration facilities and monitors compliance.
Closure Date:
5 The Under Secretary for Health coordinates with VA Office of Security and Law Enforcement to provide direction that facility policy or guidance include facility and jurisdiction-specific information necessary for frontline staff to act in accordance with jurisdiction and Veterans Health Administration requirements for VA police responding to sexual assaults.
Closure Date:
6 The Under Secretary for Health ensures Veterans Health Administration’s policy specifies the required elements to include in Veterans Health Administration facilities’ policies or guidance on acute sexual assault, including jurisdiction-specific requirements, and considers an online national policy with an appendix containing each facility’s supplemental information.
Closure Date:
7 The Under Secretary for Health makes certain that facility level management of acute sexual assault policy or guidance is updated to incorporate information on facility-specific resources and jurisdictional requirements as warranted, and educates staff as needed.
Closure Date:
8 The Under Secretary for Health ensures that VA Police Chiefs review facility policy and guidance for police responding to sexual assaults and update to incorporate information on facility-specific resources and processes, including jurisdictional requirements, as warranted, and educates facility police officers as needed.
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| 22-04037-32 | Comprehensive Healthcare Inspection of the VA Providence Healthcare System in Rhode Island | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Focused Professional Practice Evaluations for licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day, when it is clinically appropriate, following a positive suicide risk screen.
Closure Date:
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| 22-03772-28 | Care in the Community Summary Report for Fiscal Year 2022 | Care in the Community Healthcare Inspection | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff document veterans’ care coordination needs within the Community Care Coordination Plan note for consults assigned a level of care coordination above basic.
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff act on consults no later than two business days after receipt and document accordingly.
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff schedule community care appointments in a timely manner.
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff make three attempts to retrieve medical documentation from non-VA providers.
5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures patients in the home dialysis program receive initial and annual home visits.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff implement and sustain processes to monitor the delivery of non-VA home dialysis.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures each Veterans Integrated Service Network establishes a dialysis council.
Closure Date:
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| 21-02984-179 | Better Coordination Needed to Negotiate Consistent Prices for Prescription Eyeglasses | Review | ||
1 Coordinate with the executive director of the Prosthetic and Sensory Aids Service and officials from the Veterans Health Administration’s Procurement and Logistics Office and the VA Office of Acquisition, Logistics, and Construction to develop and implement a sourcing strategy, such as national contracts or a pricing catalog across all contracts by vendor for eyeglasses prescribed by a VA provider.
2 Coordinate with the executive directors of the Prosthetic and Sensory Aids Service and the Veterans Health Administration’s Office of Procurement to implement a process to ensure contracting officers coordinate before awarding any Veterans Integrated Service Network–level contracts for eyeglasses to make sure these vendors offer the Veterans Health Administration the best pricing that is also consistent for the same or similar items to the extent possible.
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| 22-00240-17 | Comprehensive Healthcare Inspection of the Overton Brooks VA Medical Center in Shreveport, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations for all licensed independent practitioners.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete licensed independent practitioners’ professional practice evaluations.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ professional practice evaluations.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider relevant Ongoing Professional Practice Evaluation data in reprivileging recommendations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board uses professional practice evaluation results to recommend privileges for licensed independent practitioners.
Closure Date:
6 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.
Closure Date:
7 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures Automated External Defibrillator cabinets containing naloxone have alarms set in the “on” position, contain tamper-evident seals, display laminated “N” signs, and include naloxone inspection logs and administration reference cards.
Closure Date:
8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff check inventory in clean storerooms and remove expired supplies in the Emergency Department and medical/surgical inpatient unit.
Closure Date:
9 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Environmental Management Service maintains clean floors in the Dialysis Unit and medical/surgical inpatient unit clean storage and supply rooms.
Closure Date:
10 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain safe and functional environments in the Dialysis Unit and medical/surgical inpatient unit.
Closure Date:
11 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings safe and in good repair in the intensive care and medical/surgical inpatient units.
Closure Date:
12 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff repair damaged walls in the Dental Clinic and Emergency Department.
Closure Date:
13 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff replace stained ceiling tiles in the Emergency Department and Primary Care Red Team.
Closure Date:
14 The Medical Center Director determines any additional reasons for noncompliance and ensures staff post signage where recording equipment is used in the intensive care and medical/surgical inpatient units, Dental Clinic, and Primary Care Red Team indicating the areas are subject to photography, digital imaging, video, or audio recording.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers assess whether patients’ most recent suicide attempt was their most lethal when completing the Comprehensive Suicide Risk Evaluation.
Closure Date:
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| 23-00383-21 | Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona | Hotline Healthcare Inspection | ||
1 The Facility Director reviews the more than 400 fecal immunochemical test specimens received by the laboratory to determine whether the processes completed were compliant with laboratory standards and policies, and ensures future specimens are received, accessioned, and processed by approved personnel.
Closure Date:
2 The Veterans Integrated Service Network Director provides oversight of facility leaders’ thorough review of laboratory fecal immunochemical test processing practices to ensure laboratory staff confirm that fecal immunochemical test specimens include the date the patient collected the specimen, utilize the collection date to determine stability, and accurately record and process specimens with strict adherence to specimen stability standards and Veterans Health Administration and facility policies, and monitors compliance.
Closure Date:
3 The Facility Director establishes a multidisciplinary team (laboratory, primary care, gastroenterology, quality) to conduct a system-wide evaluation of the fecal immunochemical test processes and practices across departments, identify areas for improvement (such as staff training, patient education, and standardized protocols), and implement recommended changes, and monitors for compliance and sustainment.
Closure Date:
4 The Facility Director, in consultation with the Veterans Integrated Service Network’s Chief of Pathology and Laboratory Medicine Service, modifies the facility’s pre-printed fecal immunochemical test label to clearly identify a space and prompt for the patient to record the date the specimen was collected.
Closure Date:
5 The Veterans Integrated Service Network Director, in consultation with the Pathology and Laboratory Medicine Service Program Office, Gastroenterology Program Office, and the Clinical Episode Review Team, evaluates the impact potential false-negative fecal immunochemical test results may have had on patients, and determines what measures need to be taken, including whether adverse event disclosures to patients are warranted.
Closure Date:
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| 23-00821-01 | Financial Efficiency Inspection of the VA Augusta Health Care System in Georgia | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of policy requirements and that all accruals are proper and valid, as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
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2 Collaborate with the Veterans Integrated Service Network chief financial officer and network contracting office to establish a monthly prioritized listing of contract modifications and canceled orders for goods or services that have not been addressed by contracting officers to ensure modification actions are completed.
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3 Ensure cardholders comply with prior approval, purchase card reconciliation, and record retention requirements as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases.”
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4 Develop and implement processes to ensure all necessary reports are monitored routinely and appropriate steps are taken to ensure all supply chain performance measures are maintained in compliance with policy.
Closure Date:
5 Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package in accordance with Veterans Health Administration policy.
Closure Date:
6 Develop formalized processes for monitoring and achieving efficiency targets and using available pharmacy data to make business decisions.
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7 Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration’s recommended level.
Closure Date:
8 Ensure that pharmacy staff are trained on the ScriptPro workflow system for pharmacy.
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9 Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.
Closure Date:
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| 22-00229-15 | Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System in Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff recommends continuation of privileges based on Ongoing Professional Practice Evaluation results.
Closure Date:
4 The Assistant Director for Efficiency and Improvement evaluates and determines any additional reasons for noncompliance and ensures managers comply with inpatient mental health unit environmental safety requirements.
Closure Date:
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14934