Recommendations
2132
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-03718-189 | VA’s Governance of its Personnel Suitability Program for Medical Facilities Continues to Need Improvement | Audit | ||
1 Establish robust oversight of the personnel suitability program within responsible office(s) that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
Closure Date:
2 Reimplement the monitoring program specifically required by VA Handbook 0710 as part of VA’s oversight efforts, or an appropriate equivalent, to identify and prevent systemic weaknesses in the personnel suitability program.
Closure Date:
3 Assess program resources and allocate staff as needed to prioritize oversight of the personnel suitability program within responsible office(s).
Closure Date:
4 Establish a plan to implement the updated staffing metrics for the Veterans Health Administration’s suitability function and consider using available hiring flexibilities.
Closure Date:
5 Incorporate formal data-testing procedures (and data-matching as appropriate) of HR Smart and the VA Centralized Adjudication Background Investigation System (or any replacement systems) into the monitoring program discussed in recommendation 2.
Closure Date:
6 Develop and execute a plan to collect, maintain, and access sufficient and appropriate data through a single system to support the tracking of background investigations from initiation to adjudication.
Closure Date:
7 Establish a plan to ensure that future systems support the functionality needed to effectively oversee and manage the background investigation process, including addressing limitations identified in the current systems and incorporating the fields necessary to track timeliness metrics.
Closure Date:
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| 23-00089-144 | Information Security Inspection at the VA Beckley Healthcare System in West Virginia | Information Security Inspection | ||
1 The assistant secretary for information and technology and chief information officer implement a process to minimize the Information Central Analytics and Metrics Platform data reliability issues.
Closure Date:
2 The assistant secretary for information and technology and chief information officer improve vulnerability management processes to ensure system changes occur within organization timelines.
Closure Date:
3 The assistant secretary for information and technology and chief information officer develop and approve an authorization to operate for the special-purpose system.
Closure Date:
4 The assistant secretary for information and technology and chief information officer include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.
Closure Date:
5 The assistant secretary for information and technology and chief information officer implement improved mechanisms to ensure system stewards are creating plans of action and milestones for all controls that have not been implemented or assessed.
Closure Date:
6 The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with special-purpose systems.
Closure Date:
7 The VA medical center director install uninterruptible power supplies to eliminate single points of electrical failure supporting the facility.
Closure Date:
8 The VA medical center director ensure that hot and cold aisles in computer rooms, and electric and data cables are installed in accordance with VA standards.
Closure Date:
9 The VA medical center director validate that appropriate physical and environmental security measures are implemented and functioning as intended.
Closure Date:
10 The VA medical center director implement media sanitization methods in accordance with VA policy requirements.
Closure Date:
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| 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:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $28,100,000
Total: $28,100,000
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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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| 22-02666-214 | 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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| 22-00230-190 | 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:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $13,000,000
Total: $13,000,000
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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.
Closure Date:
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.
Closure Date:
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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| 22-00234-200 | 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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15353