Recommendations
2060
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-01624-143 | Manufacturers Failed to Make Some Drugs Available to Government Agencies at a Discount as Required | Review | ||
1 Issue guidance clarifying that allergens are exempt from the public law and include how the determination was reached.
Closure Date:
2 Formalize and communicate the process for manufacturers to request exemptions.
Closure Date:
3 Formalize the internal process for granting exemptions.
Closure Date:
4 Establish a procedure for monitoring covered drugs identified in this report as not commercially sold.
Closure Date:
5 Develop a procedure to monitor covered drugs identified in this report as newly launched to ensure they have an established ceiling price, and make certain they are made available on the Federal Supply Schedule at the end of the 75-day period.
Closure Date:
6 Request that noncompliant manufacturers identified by the Office of Inspector General conduct a self-audit and submit their findings for remediation.
Closure Date:
7 Engage with the Food and Drug Administration to ensure that when manufacturers request new national drug codes, they are made aware of the public law requirements.
Closure Date:
8 Require contracting staff at the National Acquisition Center to conduct a covered drug check for all of a manufacturer’s drugs when any pharmaceutical Federal Supply Schedule proposal or product addition modification is submitted.
Closure Date:
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| 22-02666-214 | Comprehensive Healthcare Inspection of the St. Cloud VA Health Care System in Minnesota | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete suicide safety plans for patients with a positive suicide risk screen who are determined safe for discharge home from the urgent care center.
Closure Date:
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| 22-00236-212 | Comprehensive Healthcare Inspection of the Wilkes-Barre VA Medical Center in Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 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:
2 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct comprehensive environment of care inspections at the required frequency
Closure Date:
3 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.
Closure Date:
4 The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation within the required time frame for patients with a positive suicide risk screen.
Closure Date:
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| 22-00507-211 | A Patient’s Suicide Following Veterans Crisis Line Mismanagement and Deficient Follow-Up Actions by the Veterans Crisis Line and Audie L. Murphy Memorial Veterans Hospital in San Antonio, Texas | Hotline Healthcare Inspection | ||
1 The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of the patient and third-party contacts, consults with Human Resources and General Counsel Offices, and takes actions as warranted.
2 The Veterans Crisis Line Director expedites the alignment of the Medora documentation template with the VA and Department of Defense Clinical Practice Guideline and Veterans Crisis Line guidelines for suicide risk assessment classification levels.
Closure Date:
3 The Veterans Crisis Line Director ensures and strengthens the quality management oversight of staff who provide crisis management services, including overtime coverage.
Closure Date:
4 The Veterans Crisis Line Director confirms the retention of crisis management text conversations and establishes supervisory oversight protocols.
Closure Date:
5 The Veterans Crisis Line Director ensures issue briefs accurately reflect the action plan.
Closure Date:
6 The Veterans Crisis Line Director identifies criteria for immediate internal reviews of customers’ deaths by suicide and accidental overdose to identify crisis management and administrative performance improvement actions.
Closure Date:
7 The Veterans Crisis Line Director conducts a full review of the patient’s text contact, determines whether an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
8 The Veterans Crisis Line Director monitors compliance with the submission and oversight of notification of a customer’s death, including timely submission of a suicide prevention coordinator consult.
Closure Date:
9 The Veterans Crisis Line Director conducts a review of the interactions between the Director, Quality and Training, and staff in preparation and during the Office of Inspector General healthcare inspection, educates staff on the importance of fully cooperating, responding in an open and transparent manner, and avoiding any appearance of coordination between employees, and take actions as warranted.
10 The Veterans Crisis Line Director clarifies and strengthens procedures for complaint submission, provides staff training, ensures consistency with the Veterans Health Administration directive, and monitors compliance.
Closure Date:
11 The South Texas Veterans Health Care System Director ensures that processes are established for timely death notification entry in patients’ electronic health records.
Closure Date:
12 The South Texas Veterans Health Care System Director ensures that staff adheres to the January 2022 standard operating procedures for administrative and clinical actions following a patient’s or employee’s death by suicide.
Closure Date:
13 The Veterans Crisis Line Director strengthens processes to ensure discontinuation of caring letters in a timely manner following notification of a patient’s death.
Closure Date:
14 The South Texas Veterans Health Care System Director makes certain that the Suicide Prevention Program ensures full implementation of the Behavioral Health Autopsy Program as required by the Veterans Health Administration.
Closure Date:
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| 22-00230-190 | Comprehensive Healthcare Inspection of the VA Sierra Nevada Health Care System in Reno | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures peer reviewers consistently document at least one of the nine aspects of care for Level 3 peer reviews.
Closure Date:
2 The Chief of Staff evaluates reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all final Level 3 peer reviews.
Closure Date:
3 The Director determines the reasons for noncompliance and ensures police document their response times to panic alarm testing in the mental health inpatient unit.
Closure Date:
4 The Chief of Staff or Associate Director, Patient Care Services/Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures cameras used for patient safety monitoring do not record.
Closure Date:
5 The Chief of Staff and Associate Director, Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure staff minimize risks of patients’ self-harm in the mental health inpatient unit.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff attempt weekly follow-up until mental health care is established for patients determined as intermediate or high-acute or chronic risk of suicide on the Comprehensive Suicide Risk Evaluation who are discharged home from the Emergency Department.
Closure Date:
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| 22-02293-188 | Staff Did Not Limit the Use of Schools and Training Programs That Were Only Approved for the Veteran Readiness and Employment Program | Audit | ||
1 Develop and implement procedures to ensure the Veteran Readiness and Employment Service has properly researched and clearly understands changes to the laws and regulations that govern Chapter 31–only schools and training programs.
Closure Date:
2 Review the existing manual requirements for waivers and coordinate with appropriate officials to ensure amendments to 38 United States Code § 3104(b) have been properly implemented and included in the manual.
Closure Date:
3 Train all appropriate Veteran Readiness and Employment Service regional office staff to ensure waivers are obtained for each veteran with the required documentation in accordance with the manual before approval to attend a Chapter 31–only school or training program.
Closure Date:
4 Coordinate with appropriate officials to determine whether the existing manual guidance for compliance surveys meets the requirements of 38 United States Code § 3693 as it applies to Chapter 31–only schools and training programs, and if necessary, update the manual and train appropriate Veteran Readiness and Employment Service regional office staff accordingly.
Closure Date:
5 Develop and implement monitoring processes—to include veteran waivers, compliance surveys, and completeness of electronic folders—to provide Veteran Readiness and Employment Service reasonable assurance that Chapter 31–only schools and training programs are used as intended by law and regulations.
Closure Date:
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| 22-00234-200 | Comprehensive Healthcare Inspection of the Erie VA Medical Center in Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete 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 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 service chiefs’ reprivileging recommendations are based, in part, on Ongoing Professional Practice Evaluation activities.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee considers professional practice evaluation results in decisions to recommend privileges.
Closure Date:
5 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures staff complete Comprehensive Suicide Risk Evaluations.
Closure Date:
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| 23-01011-148 | Inconsistent Guidance and Limited Oversight Contributed to Inaccurate Community Care Wait-Time Eligibility Calculations at the C.W. Bill Young VA Medical Center in Bay Pines, Florida | Review | ||
1 The under secretary for health to make sure all scheduling guidance and other materials correctly refer to the date that should be used to determine wait-time eligibility for community care.
Closure Date:
2 The under secretary for health to make sure the Office of Integrated Veteran Care provides ongoing oversight to ensure all facilities are using nationally approved scheduling tools.
Closure Date:
3 The under secretary for health to develop an oversight process to verify that schedulers are using the correct dates to calculate wait-time eligibility for community care.
Closure Date:
4 The under secretary for health to develop a mechanism to notify schedulers when it is appropriate to consider wait-time eligibility for community care regardless of which scheduling system schedulers are using.
Closure Date:
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| 22-02064-155 | VHA Faces Challenges Implementing the Appeals Modernization Act | Review | ||
1 Require the Office of Regulations, Appeals, and Policy, in coordination with the Office of General Counsel, to determine whether the Office of Dentistry and the Consolidated Patient Account Center Program have appealable benefits decisions governed by the AMA, and if so, to update program policies, processes, and procedures accordingly, including ensuring that claimants receive written decision notices that meet all act requirements.
2 Require the Office of Regulations, Appeals, and Policy to evaluate the program offices’ barriers to including all required elements in decision notices and take corrective action, seeking congressional relief if needed.
3 Using the evaluation findings from recommendation 2, require Payment Operations to update its systems to generate AMA-compliant decision notices to the extent possible.
4 Using the same evaluation findings, require the Veteran and Family Member Programs to update its systems to generate AMA-compliant decision notices to the extent possible.
5 Require the Office of Regulations, Appeals, and Policy and the program office for Member Services’ Eligibility and Enrollment Division to ensure that priority group assignment decision notices are provided with enrollment handbooks given to veterans.
6 Identify resources and assign duties to conduct quality control reviews of decision letters with program offices to remediate deficiencies.
7 Work with the Office of Information and Technology to update Caseflow to address identified VHA system requirements within specified deadlines, including adding a program identifier and facilitating entries for individuals and entities that are not veterans.
8 Establish interim tracking procedures with the program offices until Caseflow can be considered a reliable system for VHA oversight.
9 In coordination with the Office of General Counsel, seek clarification on how the reporting metrics sections of the Appeals Modernization Act apply to VHA, and then develop those measures.
10 Issue policy and other clear guidance that includes standard tracking processes and procedures, and oversight of that tracking.
11 Work with VBA and others to allow access to all VHA program offices, and ensure that those offices in turn require that staff use the Centralized Mail Portal for all decision reviews or establish another mechanism that ensures all decision reviews are tracked from request receipt through routing and processing.
12 Work with the Office of Information and Technology to determine the best way to create a central repository and identify the necessary resources to implement and maintain it.
13 Develop decision review retention standards and communicate to the relevant programs what types of claims and appeals documentation should be stored, for how long, and where.
14 Implement training on processing and tracking appeals that is mandatory for VHA staff who process decision reviews.
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| 22-02194-152 | Nonadherence to Requirements for Processing Gulf War Illness Claims Led to Premature Decisions | Review | ||
1 The under secretary for benefits update the instructions provided to examiners for completing Gulf War general medical examinations to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317 and clarify the instructions and related procedures to reflect that an examiner’s determination that a disability pattern is an undiagnosed illness or a medically unexplained illness requires a written explanation.
Closure Date:
2 The under secretary for benefits implement a plan to update the Gulf War general medical examination disability benefits questionnaire to add the definitional requirements for medically unexplained illness as outlined in 38 C.F.R.§ 3.317.
Closure Date:
3 The under secretary for benefits implement a plan to incorporate into the Gulf War general medical disability benefits questionnaires the clinical requirements listed in 38 C.F.R.§ 3.317 for an undiagnosed illness and a medically unexplained illness.
Closure Date:
4 The under secretary for benefits implement a plan to incorporate into the appropriate medical disability benefits questionnaires the diagnostic criteria for functional gastrointestinal disorders from 38 C.F.R.§ 3.317 and require examiners to provide an explanation of whether the disorder is functional or structural. This should include a requirement that any necessary testing has been completed before examiners diagnose specific functional gastrointestinal disorders.
Closure Date:
5 The under secretary for benefits update VA’s Adjudication Procedures Manual to clearly state that all the requirements of 38 C.F.R.§ 3.317 must be met to award benefits. Clarify and reiterate instructions to claims processors that benefits should only be awarded after taking into consideration the overall evidence of record.
Closure Date:
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14935