Recommendations
2111
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-01092-228 | Widespread Failures in Response to Suspected Community Living Center Resident Abuse at the VA New York Harbor Healthcare System in Queens | Hotline Healthcare Inspection | ||
1 The VA New York Harbor Healthcare System Director reviews facility processes to ensure medical and psychosocial health care for residents who report abuse, and staff are educated on the requirements.
2 The VA New York Harbor Healthcare System Director ensures that community living center nursing leaders and factfinding investigators complete factfindings in accordance with Veterans Health Administration policy.
3 The VA New York Harbor Healthcare System Director reviews responses to other incidents of suspected abuse and ensures actions are completed for resolution, including notifications.
4 The VA New York Harbor Healthcare System Director ensures community living center staff are compliant with Veterans Health Administration Prevention and Management of Disruptive Behavior Program education and training requirements.
5 The VA New York Harbor Healthcare System Director ensures community living center nursing and clinical staffs’ electronic health records documentation meets requirements for timeliness, accuracy, and completion, and takes action as needed.
6 The Under Secretary for Health ensures that VHA abuse policy addresses compliance with federal statutes and regulations, including 42 C.F.R. § 483.12, and outlines suspected elder abuse processes to notify leaders, interdisciplinary care team members, VA Police, patients’ families or designees, and state regulatory agencies; and identifies roles and responsibilities of reviewing officials for investigative reviews.
7 The VA New York Harbor Healthcare System Director ensures system abuse policies include required elements to comply with Veterans Health Administration, state, and federal regulations, including 42 C.F.R. § 483.12; and clearly outlines processes for leaders and staff when responding to suspected abuse related to reporting (for example, to interdisciplinary care team members, VA Police, family or designee, and state regulatory agencies); and conducting factfinding investigations.
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| 24-03608-203 | Inadequate Oversight Allowed a Senior Benefits Representative to Inaccurately Authorize Thousands of Decisions | Review | ||
1 Review all processing errors on cases the OIG review team identified, correct those errors to the extent possible, and report back on the results of those actions.
2 Evaluate the effectiveness of control activities specifically for authorization rate outliers and determine whether new or stronger controls are needed.
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| 25-00451-200 | VHA Did Not Effectively Oversee the Use of Manual Journal Vouchers | Audit | ||
1 Develop a plan to ensure manual journal vouchers are justified, documented, and approved before they are entered into the Financial Management System and that they are reviewed after posting to verify accuracy and support compliance, transparency, and audit readiness.
2 Require ongoing training for all staff who prepare, review, or approve manual journal vouchers, including a process to ensure that new employees complete initial training and that refresher courses are provided when policies or tools are updated.
3 Clarify expectations for using macro-enabled journal voucher tools by defining when the standardized macro must be used; establishing a process to communicate macro tool updates and prompt the adoption of newly released versions; and providing guidance, training, and user support to promote correct and consistent application of the tools.
4 Define and communicate clear oversight responsibilities for Veterans Integrated Service Network financial managers by requiring routine monitoring of documentation and compliance at facilities.
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| 23-00324-170 | Loma Linda Healthcare System’s Oversight of Community-Based Outpatient Clinic Contracts Needs Strengthening | Review | ||
1 Strengthen controls in the Office of the Assistant Director to ensure inclusion of staffing monitoring contract requirements, in coordination with the contracting officer, to meet gradual staffing level goals during start-up periods in future community‑based outpatient clinic contracts.
2 Strengthen controls to ensure data used for monitoring contract performance standards are accurate and comply with the methodology required in the contract’s Quality Assurance Surveillance Plan.
3 Review the medical staff-driven phase of the credentialing process, to ensure action plans implemented to expedite the credentialing process are effective.
4 Strengthen controls to ensure contracted staff complete required scheduling training before granting them access to VA’s scheduling system and authorizing them to make veteran appointments.
5 Review the healthcare system’s staffing augmentation plan and coordinate with the contracting officer to ensure the full costs are recovered for all Veterans Health Administration staff who provided services for which the contractor was also compensated.
6 Review the unilateral memorandum related to staffing augmentation, establish a contract modification in compliance with the Federal Acquisition Regulation provisions regarding contract changes, and ensure relevant documentation is maintained in the contract file.
7 Recover government funds expended for Veterans Health Administration staff augmented at contracted community-based outpatient clinics using full cost amounts.
8 Review and enforce staffing contingency plan requirements for the Loma Linda Healthcare System contract, including maximizing the contractor’s use of temporary replacements, or locum tenens, to minimize staffing shortages.
9 Strengthen oversight mechanisms to ensure the enforcement of staffing requirements during contract start-up in future community‑based outpatient clinic contracts before the clinics become operational.
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| 24-03319-213 | Better Guidance and Measures Would Help Optimize the Productivity of Clinical Resource Hub Physicians | Audit | ||
1 Implement procedures to monitor the data used to measure productivity to ensure the data accurately reflect the complete work of clinical resource hub physicians.
2 Work with appropriate officials, such as Office of Primary Care and clinical resource hub leaders, to determine whether hub physicians should be subject to existing productivity measures. If so, issue clear hubs guidance requiring adherence; if not, clearly define what should be used, and issue thorough guidance on the steps hubs must take to measure physician productivity consistently.
3 Clarify oversight responsibilities for monitoring productivity measures, including detailed procedures and actions that should be taken when thresholds are not met.
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| 24-02634-229 | Deficiencies in Consult Management in the Endocrinology Service at the VA Fayetteville Coastal Healthcare System in North Carolina | Hotline Healthcare Inspection | ||
1 The VA Fayetteville Coastal Healthcare System Director reviews the endocrine consult management process and takes actions as needed to ensure compliance with current Veterans Health Administration directives and guidance.
2 The VA Fayetteville Coastal Healthcare System Director implements a strategy to review patients affected by delayed endocrine consults to evaluate whether harm occurred and the appropriateness of institutional disclosures.
3 The VA Fayetteville Coastal Healthcare System Director ensures a sustainable and effective service line agreement between endocrine and primary care services is developed and agreed upon by both services, and monitors implementation.
4 The VA Fayetteville Coastal Healthcare System Director confirms effective utilization of endocrine clinic appointments to ensure timely access to care.
5 The VA Fayetteville Coastal Healthcare System Director ensures a process is in place for monitoring and tracking clinic profile modification requests.
6 The VA Mid-Atlantic Health Care Network Director reviews the leadership performance of the chief of medicine related to communication and collaboration and takes action as necessary.
7 The VA Fayetteville Coastal Healthcare System Director evaluates communication gaps identified in this report between leaders of primary care and the Medicine Service and takes action to ensure consistency with Veterans Health Administration High Reliability Organization goals.
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| 24-00599-202 | Healthcare Facility Inspection of the Jonathan M. Wainwright Memorial VA Medical Center in Walla Walla, Washington | Healthcare Facility Inspection | ||
1 Executive leaders ensure there are clear signs during construction projects, and maps at the main entrance information desk to help veterans navigate the facility.
2 The Medical Center Director ensures contractors inspect and test emergency generators and fire doors as required, and staff report compliance to an environment of care committee.
3 The Medical Center Director ensures an environment of care committee meets, as required.
Closure Date:
4 The Associate Director of Patient Care Services/Nurse Executive ensures nursing staff monitor proper food clean-up, storage, and disposal in the Mental Health Residential Rehabilitation Treatment Program’s areas.
5 The Medical Center Director ensures staff refill hands-free sanitizer dispensers throughout the facility.
6 The Medical Center Director ensures the emergency management plan includes guidance for managing shelter-in-place supplies.
Closure Date:
7 Executive leaders ensure staff develop service-level workflows for the communication of test results for each service.
8 The Medical Center Director ensures staff implement a process to monitor providers’ compliance with communicating abnormal test results to patients.
9 Executive leaders ensure staff complete improvement actions from root cause analyses within one year.
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| 23-02507-210 | Deficiencies in VA Homeless Program Intake Documentation, Suicide Risk Assessment, and Care Coordination Processes | National Healthcare Review | ||
1 The Under Secretary for Health ensures that VA homeless program staff consistently document, in patients’ electronic health records, the clinical information from the Homeless Operations Management and Evaluation System.
2 The Under Secretary for Health makes certain that a suicide risk screening is completed with patients during intake into VA homeless programs, consistent with Veterans Health Administration policy.
3 The Under Secretary for Health ensures that staff complete suicide risk screening in response to danger of self-harm identified in the Homeless Operations Management and Evaluation System.
4 The Under Secretary for Health makes certain that homeless program staff provide and document care coordination to address patients’ mental health and substance use disorder treatment needs as identified in the Homeless Operations Management and Evaluation System.
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| 24-03418-205 | Healthcare Facility Inspection of the VA Alexandria Healthcare System in Pineville, Louisiana | Healthcare Facility Inspection | ||
1 Facility leaders ensure providers who order tests communicate the results to patients timely.
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| 23-03189-148 | Weak Governance Threatens the Viability of a Major Construction Project at the Palo Alto VA Medical Center in California | Review | ||
1 Ensure the Palo Alto major construction project (project number 640-424) is brought into the Acquisition Program Management Framework.
2 Ensure the activities and artifacts required during the verify phase of the Acquisition Program Management Framework are completed for the Palo Alto major construction project (project number 640-424)—including a business case with cost, schedule, and performance goals approved by the Secretary.
3 Ensure a decision event to verify the need of the acquisition is conducted for the Palo Alto major construction project (project number 640-424) and a determination is made to terminate or continue this project based on VA’s strategic needs and the VA Palo Alto Health Care System’s clinical needs.
4 Ensure VA’s FY 2025 Agency Capital Plan is revised to show the Palo Alto major construction project’s current total estimated cost and the progress the project has made toward meeting its critical objectives.
Closure Date:
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