Recommendations
2062
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-03133-48 | Office of Emergency Management Has Not Deployed a Functional Last-Resort Emergency Communications System | Audit | ||
1 Ensure medical facilities monitor resilient high-frequency radio network training and staffing levels and maintain enough trained staff to operate the resilient high-frequency radio network.
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2 Ensure that the appropriate stakeholders know the program office responsible for the resilient high-frequency radio network and understand the roles and responsibilities for the Veterans Health Administration’s Resilient High-Frequency Radio Network program.
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3 Finalize the Veterans Health Administration High-Frequency Radio Operations Plan.
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4 If additional resilient high-frequency radio network equipment is purchased, work with the contracting officer to provide guidance to facility representatives to ensure they verify radios are fully functional before acceptance.
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5 Conduct a risk assessment and provide guidance for the placement of resilient high-frequency radio networks within facilities and any needed monitoring schedules.
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6 Ensure sites can obtain repairs for broken or inoperable resilient high-frequency radio network equipment.
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| 22-01594-86 | Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida | Hotline Healthcare Inspection | ||
1 The West Palm Beach VA Healthcare System Director ensures that pulmonary providers communicate and document test results and surveillance care plans to patients.
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2 The West Palm Beach VA Healthcare System Director ensures that pulmonary providers and staff are trained on the use of return-to-clinic orders and monitors for compliance.
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3 The West Palm Beach VA Healthcare System Director ensures that chiropractor providers review community care notes and takes action as needed.
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| 21-03680-80 | Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, IN | Hotline Healthcare Inspection | ||
1 The Richard L. Roudebush VA Medical Center Director conducts a comprehensive review of the patient’s care received in the Emergency Department and primary care setting, consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted, and takes action.
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2 The Richard L. Roudebush VA Medical Center Director evaluates the Emergency Department alcohol withdrawal treatment protocol and ensures policy aligns with evidence-based care guidelines.
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3 The Richard L. Roudebush VA Medical Center Director considers establishing written procedures for discharge planning in the Emergency Department, including documentation of contact with family members regarding notification of discharge and follow-up when applicable.
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4 The Richard L. Roudebush VA Medical Center Director expedites written guidance for primary care staff’s care coordination of patients discharged from the Emergency Department including documentation expectations and oversight responsibilities, and monitors compliance.
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5 The Richard L. Roudebush VA Medical Center Director conducts a full review of the patient’s care, determines if an institutional disclosure is warranted, and takes action as indicated.
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6 The Richard L Roudebush VA Medical Center Director establishes a protocol for the administrative staff management of potentially urgent patient care needs, ensures training, and monitors compliance.
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7 The Richard L. Roudebush VA Medical Center Director develops procedures for the management of intoxicated patients in the primary care setting to include documentation of safe transport considerations.
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| 21-01997-69 | Improvements Needed in Integrated Financial and Acquisition Management System Deployment to Help Ensure Program Objectives Can Be Met | Audit | ||
1 Implement controls to mitigate the risk that data are unreliable and inconsistently recorded between eCMS and iFAMS when staff deobligate funds for converted contracts.
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2 Establish and implement a methodology to prioritize user feedback into the risk management process.
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3 Use the risk register to document and assess the risks associated with the manual deobligation process.
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4 Ensure that converted contracts are included in integrated system testing and user acceptance testing.
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5 Implement a process that provides formal acknowledgment on whether requests related to high-priority business intelligence reports have been accepted as requirements.
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| 22-01503-65 | Veterans Are Still Being Required to Attend Unwarranted Medical Reexaminations for Disability Benefits | Review | ||
1 Take action to help reduce unwarranted reexaminations by updating guidance and enhancing information systems to require rating specialists to cite objective evidence and provide justification for establishing reexamination controls.
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2 Consider establishing criteria to define a “locally-designated claims processor with expertise in review examination ordering” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations.
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3 Update training materials to include the guidance from VBA Policy Letter 21-01, “Updated Guidance on Routine Future Examination Requests” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations
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| 22-00036-68 | Comprehensive Healthcare Inspection of the Amarillo VA Health Care System in Texas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance using objective criteria accepted by the practitioner.
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2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews and evaluates licensed independent practitioners’ privileging requests and documents its review in the meeting minutes.
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3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete Focused Professional Practice Evaluations and document results in practitioners’ profiles.
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| 22-02721-77 | Stronger Controls Help Ensure People Barred from Paid Federal Healthcare Jobs Do Not Work for VHA | Administrative Investigation | ||
1 The chief for the Veterans Health Administration Office of Human Capital Management completes planned revisions of human resources policies and procedures to ensure that excluded individuals are not employed in paid positions using VA healthcare program funds, including requiring screening of candidates’ alternative or prior names or social security numbers (if accessible) against the List of Excluded Individuals and Entities prior to hiring.
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2 The executive director for the Veterans Health Administration Office of Integrity and Compliance implements planned revisions of policies and procedures for the Office of Integrity and Compliance to ensure it performs accurate List of Excluded Individuals and Entities monitoring, including for individuals with alternative or prior names or using social security numbers (if accessible), and provides timely notification of potential violations to appropriate staff.
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3 The executive director for the Veterans Health Administration (VHA) Office of Integrity and Compliance performs a one-time audit of VA employment records using corrected matching practices to determine whether any individuals on the List of Excluded Individuals and Entities are receiving payments using VA healthcare program funds, and, if so, whether additional revisions to policies and procedures of the VHA Office of Integrity and Compliance, the VHA Office of Human Capital Management, or any other element of VA are required to address the causes, including any related screening and/or monitoring process failures.
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| 22-01814-36 | VBA Did Not Ensure Complex Appeals Were Decided by Appropriate Staff | Review | ||
1 Incorporate oversight to periodically ensure decisions issued for complex appeals were completed by DROC employees that met all requirements associated with them.
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2 Ensure DROCs identify which raters meet all the requirements to issue decisions on complex appeals, and to communicate to managers and staff which raters meet those requirements.
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3 Provide guidance to DROC supervisors on how to maintain VBMS routing rules, and have OAR establish a procedure to periodically ensure WIT and workload designations at the DROCs are in alignment.
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4 Ensure the St. Petersburg DROC monitors the effectiveness of its modified procedures that only designated DROs are assigned informal conferences for complex appeals, and ensure complex appeal designation will be accounted for in future informal conference routing applications.
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| 21-01836-66 | Deficiencies in the Implementation and Leadership Oversight of Ketamine at the Eastern Oklahoma VA Health Care System in Muskogee | Hotline Healthcare Inspection | ||
1 The Eastern Oklahoma VA Health Care System Director evaluates the Eastern Oklahoma VA Health Care System’s non-formulary medication request and appeal processes for ketamine and antipsychotic medication, implements necessary changes, and educates prescribing providers and pharmacists on the processes.
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2 The Eastern Oklahoma VA Health Care System Director ensures that the Eastern Oklahoma VA Health Care System staff document informed consents for stellate ganglion blocks and intravenous ketamine treatment in accordance with Veterans Health Administration policy.
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3 The Eastern Oklahoma VA Health Care System Director evaluates the standard operating procedure, Psychiatric Use of IV Ketamine, Eastern Oklahoma VA Healthcare System, and specifically delineates the mechanisms for referral and evaluation of patients, to include documentation of criteria for patients to receive ketamine treatment and ensures staff are educated and compliant with the procedure.
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4 The Eastern Oklahoma VA Health Care System Director takes action to ensure Eastern Oklahoma VA Health Care System leaders continue to resolve disagreements between prescribers and pharmacists and foster the development of positive working relations among Anesthesiology, Pharmacy, and Psychiatry Services.
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5 The Under Secretary for Health evaluates the VA Ketamine Infusion for Treatment-Resistant Depression and Severe Suicidal Ideation National Protocol Guidance to determine whether the acceptable number of previous treatment failures in a current episode of depression should be modified to align with current scientific recommendations.
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| 22-00901-78 | Opioid Safety at the VA Northern California Health Care System in Mather | Hotline Healthcare Inspection | ||
1 The VA Northern California Health Care System Director will ensure development and implementation of a VA Northern California Health Care System prescription drug monitoring program policy as required by Veterans Health Administration Directive 1306(1), Querying State Prescription Drug Monitoring Programs (PDMP).
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2 The VA Northern California Health Care System Director verifies the VA Northern California Health Care System pain management policy is in alignment with Veterans Health Administration Directive 1005, Informed Consent for Long-Term Opioid Therapy for Pain.
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14943