Recommendations
2060
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-03806-162 | VA Should Ensure Veterans’ Records in the New Electronic Health System Are Reviewed before Deciding Benefits Claims | Review | ||
1 Conduct national refresher training on the Electronic Health Record Modernization National Process Memorandum and assess training effectiveness
Closure Date:
2 Consider updating VA Manual 21-4 to reflect that quality assurance measures include addressing failures to consider all Veterans Health Administration records as directed in the Adjudication Procedures Manual that are subject to an enterprise-wide search in the Compensation and Pension Records Interchange system whether or not directed to those records by the claimant and ensure staff are advised of the changes.
Closure Date:
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| 22-01230-185 | Deficiencies in Echocardiogram Interpretation Timeliness, Facility Policies, Patient Safety Reporting, and Oversight at the Fayetteville VA Coastal Health Care System in North Carolina | Hotline Healthcare Inspection | ||
1 The Fayetteville VA Coastal Health Care System Director ensures time frames for interpretation of echocardiograms are formalized and monitors for compliance.
Closure Date:
2 The Fayetteville VA Coastal Health Care System Director reviews Facility Policy 11-40, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge dated January 2022 and SOP 11-10, Adult Intensive Care Unit (ICU) Admission, Triage and Discharge Standard Operating Procedure and confirms that policy and procedures for an admission requiring continuous renal replacement therapy align with equipment and trained staff available at the facility.
Closure Date:
3 The Fayetteville VA Coastal Health Care System Director ensures facility staff are educated on the community living center delineation of after-hour coverage and monitors compliance.
Closure Date:
4 The Fayetteville VA Coastal Health Care System Director confirms hospitalists are educated on reporting patient safety issues and monitors patient safety reporting compliance.
Closure Date:
5 The VA Mid-Atlantic Health Care Network Director reviews privileging processes and policies to ensure that facility leaders follow privileging processes and monitors compliance.
Closure Date:
6 The Fayetteville VA Coastal Health Care System Director requires the chief of medicine to use focused professional practice evaluations and ongoing professional practice evaluations to evaluate provider performance per policy and monitors compliance.
Closure Date:
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| 22-03768-156 | Financial Efficiency Inspection of the VA Milwaukee Healthcare System | Financial Inspection | ||
1 The VA Milwaukee Healthcare System director to establish a plan to use VA’s cost accounting system information for the development of relevant, detailed cost information and to identify alternative ways to reduce costs and enhance efficiency as identified by VA financial policy.
Closure Date:
2 The VA Milwaukee Healthcare System director to consider a plan to align VA Milwaukee Healthcare System financial management practices with federal financial accounting standard practices. This could include using cost information for performance measurement, budgeting and cost control, and making economic choices.
Closure Date:
3 The VA Milwaukee Healthcare System director to ensure initiating services communicate status of delivered orders in a timely manner so healthcare system finance staff can comply with VA Financial Policy, vol. 2, chap. 5, “Obligations Policy,” by ensuring monthly that proper accruals have occurred.
Closure Date:
4 The VA Milwaukee Healthcare System director to 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.
Closure Date:
5 The Veterans Integrated Service Network 12 director to work with the network contracting office to amend the current contract or establish a new contract to include all needed laboratory tests.
Closure Date:
6 The VA Milwaukee Healthcare System director to establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.
Closure Date:
7 The VA Milwaukee Healthcare System director to require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
Closure Date:
8 The VA Milwaukee Healthcare System director to develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package per Veterans Health Administration policy.
Closure Date:
9 The VA Milwaukee Healthcare System director to develop better access controls over the contingency space, to ensure less accessibility to reduce missing inventory.
Closure Date:
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| 22-00055-184 | Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System in California | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
Closure Date:
2 The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct a root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
3 The Chief of Staff evaluates and determines reasons for noncompliance and ensures section or service chiefs define time frames for Focused Professional Practice Evaluations.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures Medical Executive Council meeting minutes consistently contain its recommendations for privileging requests
Closure Date:
6 The Associate Director, Operations evaluates and determines any additional reasons for noncompliance and ensures staff inspect, test, and maintain all medical equipment.
Closure Date:
7 The Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain equipment and furnishings in good working order and keep areas used by patients clean, safe, and suitable for care.
Closure Date:
8 The Director evaluates and determines reasons for noncompliance and ensures that only breathable shower curtains are present in mental health inpatient unit bathrooms.
Closure Date:
9 The Chief of Staff or Associate Director, Patient Care Service/Nurse Executive determines the reasons for noncompliance and ensures video or audio monitoring equipment installed for patient safety purposes does not record and is only accessed and viewed by Veterans Affairs healthcare providers.
Closure Date:
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| 21-01295-149 | Additional Measures Would Better Protect Borrowers from Risks Associated with Interest Rate Reduction Refinance Loans | Audit | ||
1 The OIG recommended the under secretary for benefits assess the loan comparison statement controls implemented in December 2021 and 2022 to ensure they operate as planned and confirm borrowers receive these statements as required.
Closure Date:
2 The OIG recommended the under secretary for benefits seek a legal opinion from the VA’s Office of General Counsel on the allowability of fees initially charged as itemized fees to be retroactively accepted as part of the 1 percent flat charge if unsupported, and then review the potential overcharges identified in the audit sample to determine if action is needed to make the borrowers whole.
Closure Date:
3 The OIG recommended the under secretary for benefits develop and update policies and procedures to ensure invoices or bills are obtained for all third-party charges and lenders report itemized closing costs at the lowest level of detail.
Closure Date:
4 The OIG recommended the under secretary for benefits develop and update policies and procedures for the state deviation process and requirements, assess the extent of missing VA authorizations on the schedule of state deviations and obtain the necessary documentation, and obtain a legal opinion from the VA’s Office of General Counsel on the allowability of state deviation charges in excess of the state-published amounts, and then review the potential overcharges identified in the audit sample to determine if action is needed to make the borrowers whole.
Closure Date:
5 The OIG recommended the under secretary for benefits revise policies and procedures to comply with federal regulations on the itemization of costs charged under the 1 percent flat charge to ensure closing costs are properly charged.
Closure Date:
6 The OIG recommended the under secretary for benefits obtain a legal opinion from the VA’s Office of General Counsel on the allowability of mortgage brokerage fees charged under the 1 percent flat charge, and then review the potential overcharge identified in the audit sample to determine if action is needed to make the borrower whole.
Closure Date:
7 The OIG recommended the under secretary for benefits provide lenders at least annual communication about the importance of providing justifications for any loans not reported within 60 days.
Closure Date:
8 The OIG recommended the under secretary for benefits modify policies and procedures for full-file loan reviews to include detailed steps for loan specialists to conduct reviews, as well as the risk factors and methodology for loan selection.
Closure Date:
9 The OIG recommended the under secretary for benefits update policies and procedures to ensure the borrower is reimbursed for any overcharges identified during regional loan center quality reviews.
Closure Date:
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| 22-00029-183 | Leaders’ Failure to Resolve Cardiology Department Challenges at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana | Hotline Healthcare Inspection | ||
1 The Richard L Roudebush VA Medical Center Director ensures the Chief of Staff, chief of medicine, and chief of cardiology, in consultation with the National Cardiology Program Office, reevaluate the Cardiology Department and establish and implement a long-term service plan that includes cardiology services and cardiologist and specialty cardiologist staffing levels.
Closure Date:
2 The Richard L Roudebush VA Medical Center Director provides the chief of cardiology with the dedicated resources needed to develop, implement, and sustain Cardiology Department changes.
Closure Date:
3 The Veterans Integrated Service Network Director provides oversight of the Richard L Roudebush VA Medical Center Director’s development and implementation of a long-term Cardiology Department plan, monitors the department’s progress, and ensures changes are sustained.
Closure Date:
4 The Veterans Integrated Service Network Director ensures the Richard L Roudebush VA Medical Center Director continues to strengthen and maintain the Cardiology Department’s relationship with the university affiliate, including residency and fellow cardiology programs and joint efforts to recruit cardiologists.
Closure Date:
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| 22-03543-151 | The Fiduciary Program Needs to Verify the Prompt Return of Deceased Beneficiaries’ Funds to VA | Review | ||
1 The Pension and Fiduciary Service clarifies procedural requirements to fiduciary hub staff on how to verify whether VA-derived funds of deceased beneficiaries must be returned to VA, including whether the fiduciary identified any valid will or heir to whom the funds are otherwise due.
Closure Date:
2 The Pension and Fiduciary Service considers reimplementing the procedural requirement to verify the disbursement of VA-derived funds to deceased beneficiaries’ estates when a valid will or heir exists.
Closure Date:
3 The Pension and Fiduciary Service identifies existing or implements new electronic controls that allow VBA staff to track Fiduciary Program tasks, timeliness, and workload related to the return of deceased beneficiaries’ VA-derived funds to VA that would otherwise escheat to a state if not disbursed to heirs.
Closure Date:
4 The Pension and Fiduciary Service and the Office of Field Operations establish a methodology and monitor workload to ensure the prompt return of deceased beneficiaries’ VA-derived funds.
Closure Date:
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| 22-01511-174 | Concern with Veterans Health Administration’s Lung Cancer Screening Program Requirements | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by allowing a facility to conduct lung cancer screening while developing all mandated elements.
Closure Date:
2 The Under Secretary for Health reviews the operational memorandum for lung cancer screening implementation and assesses whether lung cancer screening rates could be enhanced by reevaluating, prioritizing, and clarifying the mandated elements.
Closure Date:
3 The Under Secretary for Health considers mandating eligible patients be offered lung cancer screening consistent with other required cancer screening in the Veterans Health Administration.
Closure Date:
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| 22-00069-177 | Comprehensive Healthcare Inspection of the Lebanon VA Medical Center in Pennsylvania | 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:
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| 22-00068-171 | Comprehensive Healthcare Inspection of the Butler VA Health Care System in Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager initiates an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
2 The Executive Director determines any additional reasons for noncompliance and ensures leaders maintain a clean and safe environment.
Closure Date:
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14935