Recommendations
2062
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00488-81 | VA Developed Reporting Metrics for Appeals Modernization Act Decision Reviews but Could Be Clearer on Some Veterans’ Wait Times | Review | ||
1 Update the reporting methodology used in public reports to reflect the total time veterans wait for a final claims decision when their higher level reviews require a supplemental claim be established and completed due to an error.
Closure Date:
2 Revise and clearly state the measures used for calculating and reporting the average duration, from the filing of an initial claim until the claim is resolved and claimants no longer take any action under the Appeals Modernization Act claim, and ensure consistency with subsection M of the act.
Closure Date:
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| 22-02989-103 | Financial Efficiency Inspection of the VA New York Harbor Healthcare System | Financial Inspection | ||
1 The VA New York Harbor Healthcare System director to ensure that healthcare system finance office staff and initiating services are aware of policy requirements to conduct reviews on all inactive open obligations and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 The VA New York Harbor Healthcare System director to ensure that healthcare system finance office staff and initiating services that healthcare system staff are conducting finance quality assurance reviews of obligations that were inactive for more than 90 days, as required by Veterans Health Administration Directive 1733, “VHA Finance Quality Assurance Reviews.”
Closure Date:
3 The VA New York Harbor Healthcare System director to ensure cardholders comply with record retention, prior approval, and purchase card reconciliation requirements as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases.”
Closure Date:
4 The VA New York Harbor Healthcare System director to ensure cardholders verify that vendors have removed all state and local sales taxes from orders, if applicable.
Closure Date:
5 The VA New York Harbor Healthcare System director to ensure authorizing officials implement internal controls over government purchase card activities to ensure compliance with the Government Purchase Card Program.
Closure Date:
6 The VA New York Harbor Healthcare System director to establish internal controls to help ensure the healthcare system monitors the Medical/Surgical Prime Vendor formulary for updates, converts supplies to the prime vendor in the item master file, identifies the prime vendor as the mandatory source for these items in the Generic Inventory Package, and properly sets up Medical/Surgical Prime Vendor supply items in VA’s ordering system.
Closure Date:
7 The VA New York Harbor Healthcare System director to develop a plan to improve collaboration with the prime vendor and its on-site representative to ensure adequate stock is available to meet orders, reduce the need for the healthcare system to use nonprime vendors, and communicate the healthcare system’s usage and in-stock timing needs.
Closure Date:
8 The VA New York Harbor Healthcare System director to ensure a qualified Medical/Surgical Prime Vendor contracting officer’s representative is appointed and performs the required delegated duties.
Closure Date:
9 The VA New York Harbor Healthcare System director to establish internal controls to help ensure the healthcare system submits national contract waivers and justifications prior to purchasing available formulary items from nonprime vendor sources.
Closure Date:
10 The VA New York Harbor Healthcare System director to ensure that prime vendor contract performance issues are routinely reported to the Medical Supplies Program Office and Strategic Acquisition Center using established Veterans Health Administration reporting tools.
Closure Date:
11 The VA New York Harbor Healthcare System director to develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
12 The VA New York Harbor Healthcare System director to develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration’s recommended level.
Closure Date:
13 The VA New York Harbor Healthcare System director to develop and implement a plan to report the results of facility-based inventory audits of noncontrolled drug line items, and any follow-up actions taken, as required by Veterans Health Administration policy.
Closure Date:
14 The VA New York Harbor Healthcare System director establish processes to ensure compliance with the Veterans Health Administration directive which requires that B09 reconciliations are signed by the lead pharmacy technician and include appropriate supporting documentation.
Closure Date:
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| 22-03483-133 | Inadequate Community Living Center Processes and Training at the West Texas VA Health Care System in Big Spring | Hotline Healthcare Inspection | ||
1 The West Texas VA Health Care System Director ensures that community living center nursing staff are trained on their roles, responsibilities, and necessary actions when responding to a medical emergency.
Closure Date:
2 The West Texas VA Health Care System Director certifies that mock codes are completed within the community living center at regular intervals and include all community living center nursing staff.
Closure Date:
3 The West Texas VA Health Care System Director ensures that documentation requirements are met by community living center clinical staff and monitors compliance.
Closure Date:
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| 22-02961-71 | Inspection of Information Security at the St. Cloud VA Medical Center in Minnesota | Information Security Inspection | ||
1 The assistant secretary for information and technology and chief information officer implement a more effective vulnerability management program to identify all critical security deficiencies on the network and to remediate vulnerabilities within policy timelines.
2 The assistant secretary for information and technology and chief information officer implement a more effective inventory process to identify network devices.
Closure Date:
3 The assistant secretary for information and technology and chief information officer implement processes to prevent the use of prohibited software on agency devices.
Closure Date:
4 The assistant secretary for information and technology and chief information officer test the emergency power bypass during annual uninterruptible power supply testing and document results.
Closure Date:
5 The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with medical devices and special-purpose systems.
Closure Date:
6 The assistant secretary for information and technology and chief information officer ensure access authorization memorandums are present in all communication rooms.
Closure Date:
7 The assistant secretary for information and technology and chief information officer ensure that physical access for the data center and communication rooms are reviewed on a quarterly basis.
Closure Date:
8 The assistant secretary for information and technology and chief information officer ensure visitor access records are available and reviewed on a quarterly basis.
Closure Date:
9 The St. Cloud VA Medical Center director ensure video surveillance systems are operational and monitored for the data center.
10 The St. Cloud VA Medical Center director ensure communication rooms with infrastructure equipment have adequate environmental controls.
Closure Date:
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| 22-00228-127 | Comprehensive Healthcare Inspection of the Manila VA Clinic in Pasay City, Philippines | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board recommends continuation of privileges based, in part, on Ongoing Professional Practice Evaluation results.
Closure Date:
2 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures providers complete Comprehensive Suicide Risk Evaluations on the same day as patients’ positive suicide risk screens.
Closure Date:
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| 22-00046-126 | Comprehensive Healthcare Inspection of the New Mexico VA Health Care System in Albuquerque | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Executive Leadership Board recommends, implements, and monitors improvement actions.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for Level 3 peer reviews.
Closure Date:
3 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff either conduct an individual root cause analysis for all events receiving an actual or potential safety assessment code score of three or include the events in an aggregated review.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures providers with similar training and privileges complete licensed independent practitioners’ Focused Professional Practice Evaluations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend licensed independent practitioners’ continued privileges based on Ongoing Professional Practice Evaluation activities.
Closure Date:
6 The Assistant Director determines the additional reasons for noncompliance and ensures staff maintain, inspect, and test biomedical equipment according to the manufacturer’s recommendations.
Closure Date:
7 The Associate Director and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff remove supplies from shipping cartons and corrugated boxes prior to putting them in clean storage areas.
Closure Date:
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| 22-02960-70 | Inspection of Information Security at the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania | Information Security Inspection | ||
1 Verify and make necessary corrections to the systems’ component inventory in the VA’s Enterprise Mission Assurance Support Service.
Closure Date:
2 Improve vulnerability management processes to ensure system changes occur within organization timelines.
Closure Date:
3 Develop and approve an authorization to operate for the special-purpose system.
Closure Date:
4 Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
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| 22-00038-125 | Comprehensive Healthcare Inspection of the VA North Texas Health Care System in Dallas | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines additional reasons for noncompliance and ensures leaders conduct and accurately document institutional disclosures for applicable sentinel events.
Closure Date:
2 The Assistant Director Clinical Services evaluates and determines any additional reasons for noncompliance and ensures mental health staff attempt weekly follow-up until care is established for patients discharged from the emergency department who are at intermediate or high acute or chronic risk of suicide.
Closure Date:
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| 23-00237-124 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2022 | Review | ||
1 The under secretary for benefits reduces improper and unknown payments to below 10 percent for the Pension Program.
Closure Date:
2 The under secretary for health reduces improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program.
Closure Date:
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| 21-03598-92 | Goals Not Met for Implementation of the Beneficiary Travel Self-Service System | Review | ||
1 Director of the Veterans Transportation Program determines what system changes are needed to meet auto-adjudication goals and implement these changes.
Closure Date:
2 Director of the Veterans Transportation Program conducts outreach to users, solicits feedback, and considers whether system changes are needed based on feedback, to increase self-service portal usage.
Closure Date:
3 Assistant Under Secretary for Health for Operations create an action plan to phase out continued use of the VistA beneficiary travel function.
Closure Date:
4 Assistant Under Secretary for Health for Operations coordinates with the veteran’s health administration office of finance and assess whether duplicate payments were made to veterans requesting travel reimbursement since the new system went live.
Closure Date:
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14943