Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00814-230 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2021 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures healthcare providers inform patients and/or caregivers when a medication is not FDA-approved; provide the option to refuse the medication; and advise them of the known risks, benefits, and alternatives prior to administration.
Closure Date:
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| 21-03061-209 | Improved Processing Needed for Veterans’ Claims of Contaminated Water Exposure at Camp Lejeune | Review | ||
1 Centralize all Camp Lejeune-related claims processing at the Louisville VA Regional Office, or implement a plan and report progress mitigating the error rate disparity between the Louisville Regional Office and other regional offices.
Closure Date:
2 Conduct and report to the Office of Inspector General the results of targeted quality reviews of Camp Lejeune-related claims from all regional offices processing these claims until the accuracy rate meets or exceeds the Veterans Benefits Administration’s overall national accuracy goal for disability compensation claims.
Closure Date:
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| 21-03595-219 | Failure to Communicate and Coordinate Care for a Community Living Center Resident at the VA Greater Los Angeles Health Care System in California | Hotline Healthcare Inspection | ||
1 The VA Greater Los Angeles Health Care System Director confirms that a process is in place to ensure community living center staff have knowledge of policies pertaining to nursing practice and documentation in the community living center.
Closure Date:
2 The VA Greater Los Angeles Health Care System Director ensures all nursing staff assigned to the community living center have received training on the completion and documentation of all required elements for pain assessments.
Closure Date:
3 The VA Greater Los Angeles Health Care System Director verifies that community living center nursing staff demonstrate knowledge of the procedure for managing verbal and telephone orders and monitors compliance.
Closure Date:
4 The VA Greater Los Angeles Health Care System Director reviews the Greater Los Angeles Healthcare System hand-off communication policy to determine if changes are warranted to
address the procedure for managing hand-offs, ensures understanding of policy by staff, and monitors compliance.
Closure Date:
5 The VA Greater Los Angeles Health Care System Director verifies that community living center staff are aware of events warranting submission of a Joint Patient Safety Report and how to submit one.
Closure Date:
6 The VA Greater Los Angeles Health Care System Director evaluates the circumstances surrounding the death of the resident and determines if peer reviews of relevant clinical staff are warranted.
Closure Date:
7 The VA Greater Los Angeles Health Care System Director ensures that community living center managers receive training on the types of reviews, including quality assurance and administrative investigations and when each is appropriate for use, and documents attendance.
Closure Date:
8 The VA Greater Los Angeles Health Care System Director ensures that actions identified in the Corrective Action Plan are tracked to completion.
Closure Date:
9 The VA Greater Los Angeles Health Care System Director confirms that an institutional disclosure is completed and documented to share that an “opportunity for intervention(transfer to the Emergency Department) existed and was considered but not acted on, prior to the terminal event.
Closure Date:
10 The VA Greater Los Angeles Health Care System Director directs community living center leaders to review policy and admission processes to ensure respiratory therapy equipment needed in the care of a resident is in place at the time of admission.
Closure Date:
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| 21-01361-192 | The Compensation Service Could Better Use Special-Focused Reviews to Improve Claims Processing | Review | ||
1 Update the special-focused review standard operating procedure to require analysis of why errors occurred.
Closure Date:
2 Establish controls to ensure special-focused review reports communicate both benefit entitlement and procedural errors.
Closure Date:
3 Establish controls to ensure special-focused review reports communicate all errors identified at both the national and regional office levels.
Closure Date:
4 Implement a process to measure the effectiveness of actions taken in response to each special-focused review and determine whether a follow-up review is needed.
Closure Date:
5 Reassess special-focused review errors marked as “corrected” to determine whether corrective actions were taken.
Closure Date:
6 Assess whether an enhancement to the Quality Management System could mitigate the risk of claims processors closing special-focused review errors without correction and develop a process to ensure corrective actions are taken on all errors.
Closure Date:
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| 21-02668-182 | Digital Divide Consults and Devices for VA Video Connect Appointments | Review | ||
1 Establish clear oversight roles and responsibilities of the program office and of regional network telehealth and medical facility leads to monitor medical facility social worker and telehealth staff compliance with the “Digital Divide Standard Operating Procedure” for conducting assessments, ordering, and scheduling.
Closure Date:
2 Develop and implement a mechanism to alert the requesting clinic that a patient has a loaned device and can now be scheduled for a VA Video Connect appointment.
Closure Date:
3 Clarify timeliness goals for the digital divide consult, and video device order placement.
Closure Date:
4 Update the digital divide consult training to include procedure updates and ensure social workers and facility telehealth and Remote Order Entry System coordinators who process digital divide consults and video device orders complete the training and take refresher training as needed.
Closure Date:
5 Implement procedures to require responsible staff to check for duplicate devices before submitting a device order consult.
Closure Date:
6 Establish an alert in the Remote Order Entry System to notify the responsible staff member that a patient already has an issued device before ordering another, and initiate retrieval activities for duplicate devices.
Closure Date:
7 Delegate in the “Digital Divide Standard Operating Procedure” facility staff to monitor the tablet dashboard for VA Video Connect appointment activity and device use, and clearly define regional network telehealth leads’ oversight responsibilities to ensure facilities initiate retrieval activities when warranted.
Closure Date:
8 Establish an automated mechanism using the tablet dashboard to routinely identify the devices that meet retrieval priorities and also initiate retrieval of those that already meet retrieval requirements.
Closure Date:
9 Augment tracking mechanisms for packages sent to patients to ensure VA receipt of the retrieval kit so that devices are accurately recorded in inventory and available for refurbishment and reissue.
Closure Date:
10 Address restrictions in the refurbishment process, implement accessible and trackable reporting of devices waiting to be refurbished, and implement a structured purchasing model to guide new device purchases and maintain an appropriate inventory level.
Closure Date:
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| 21-02903-214 | Deficiencies in Life-Sustaining Treatment Processes at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health reviews vulnerabilities related to life-sustaining treatment processes and do not resuscitate orders within Veterans Health Administration facilities
Closure Date:
2 The Michael E. DeBakey VA Medical Center Director evaluates staff’s reliance on the electronic health record as the definitive source for verification of life-sustaining treatment orders and patients’ code statuses and takes action as indicated
Closure Date:
3 The Michael E. DeBakey VA Medical Center Director ensures that corrective actions from internal and quality management reviews are fully developed, implemented, and monitored for effectiveness.
Closure Date:
4 The Michael E. DeBakey VA Medical Center Director ensures that the electronic health record displays life-sustaining treatment orders where staff can easily locate the information.
Closure Date:
5 The Michael E. DeBakey VA Medical Center Director ensures that modifications to patients’ life-sustaining treatment orders, including do not resuscitate orders, are confirmed with the
patient and surgical team and documented in the electronic health record prior to surgical procedures requiring anesthesia.
Closure Date:
6 The Michael E. DeBakey VA Medical Center Director determines that facility staff review patients’ code statuses for any changes upon patients’ return to units after surgical procedures.
Closure Date:
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| 21-02401-190 | The Fugitive Felon Benefits Adjustment Process Needs Better Monitoring | Review | ||
1 Improve monitoring procedures and demonstrate progress toward ensuring all felony referrals are processed.
Closure Date:
2 Update fugitive felon letters and ensure they are consistently sent with all required information.
Closure Date:
3 Review unprocessed felony referrals identified in this report, take corrective action as needed, and report the efforts taken to the OIG.
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| 22-00210-191 | VA Needs to Improve Governance of Identity, Credential, and Access Management Processes | Review | ||
1 Designate roles and responsibilities for all program offices involved in VA’s identity, credential, and access management program.
Closure Date:
2 Provide appropriate oversight and ensure coordination between designated program offices to implement a comprehensive identity, credential, and access management policy.
Closure Date:
3 Update and publish a VA directive and handbook associated with identity and access management that includes current National Institute of Standards and Technology requirements.
Closure Date:
4 Update and publish VA directives and handbooks associated with the Homeland Security Presidential Directive 12 Program and VA’s personnel security and suitability program as required by VA’s enterprise directives management procedures.
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| 21-01351-151 | VBA Improperly Created Debts When Reducing Veterans’ Disability Levels | Review | ||
1 Implement a formal procedure to ensure all improperly created debts identified by the review team are corrected, and certify the results to the OIG.
Closure Date:
2 Enact a formal procedure to review all VBA compensation awards not already reviewed by the OIG that were completed since January 1, 2020, with debts due to reduced disability levels, take corrective action as appropriate, and report the results to the OIG.
3 Develop and demonstrate progress toward implementing a plan to update the electronic system to make employees aware of each period in which an award creates a debt.
Closure Date:
4 Develop a mechanism to review the effectiveness of the recommendations periodically and a process for determining what additional measures, if any, are needed.
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| 22-00066-184 | Financial Efficiency Review of the VA Black Hills Health Care System in South Dakota | Financial Inspection | ||
1 The OIG made the following recommendation to the director of the VA Black Hills Health Care System: Ensure finance office staff conduct reviews on all inactive open obligations as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 Establish procedures to ensure cardholders comply with processing requirements as stated in VA’s Financial Policy, vol. XVI, chap. 1B, “Government Purchase Card for Micro-Purchases.”
Closure Date:
3 Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
Closure Date:
4 Develop measures to confirm that completed VA Form 0242 submissions are accurate and updated for all cardholders.
Closure Date:
5 Ensure the supply chain management staff implement a plan to monitor and correct unit conversion factor errors consistently and promptly to improve data reliability in the Generic Inventory Package.
Closure Date:
6 Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration-recommended level.
Closure Date:
7 Establish measures to improve compliance with the VHA directive to avoid end-of-year pharmaceutical purchases.
Closure Date:
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