Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-03339-208 | Deficiencies in Facility Leaders’ Oversight and Response to Allegations of a Provider’s Sexual Assaults and Performance of Acupuncture at the Beckley VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Capital Health Care Network Director reviews and evaluates the March 2021 Administrative Investigation Board action plan to identify open actions and ensures completion.
Closure Date:
2 The Beckley VA Medical Center Director ensures a review of Veterans Health Administration and Beckley VA Medical Center policies related to professional practice evaluations, including supervisory roles, review periods, and service-specific data collection, and takes action as appropriate.
Closure Date:
3 The Beckley VA Medical Center Director reviews and evaluates Veterans Health Administration and Beckley VA Medical Center policies related to disclosures and quality management actions such as look-back reviews and patient safety reporting to ensure such actions are timely, objective, and documentation is sufficient to address the issue under review.
Closure Date:
4 The Beckley VA Medical Center Director ensures staff education of Veterans Health Administration and Beckley VA Medical Center policies related to employee misconduct and monitors compliance.
Closure Date:
5 The Beckley VA Medical Center Director evaluates processes for reporting providers to the state licensing boards, including initial and comprehensive reviews, and monitors compliance.
Closure Date:
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| 21-02732-153 | Airborne Hazards and Open Burn Pit Registry Exam Process Needs Improvement | Review | ||
1 Ensure the program office and VA’s Office of Information and Technology work together to revise the questionnaire to make it clearer and easier for veterans to more quickly complete the questionnaire and schedule exams.
Closure Date:
2 Improve controls to ensure the registry website maintains accurate contact information for environmental health coordinators.
Closure Date:
3 Assess the feasibility of veteran-centric guidance that assigns medical facility follow-up responsibilities and identifies processes for determining whether unscheduled veterans with an interest in an exam still want to be scheduled, and then track responses and completions.
Closure Date:
4 Implement a mechanism to ensure medical facilities meet the 90-day timeliness standard for the completion of requested exams, including performance metrics.
Closure Date:
5 Ensure Veterans Integrated Service Network and facility environmental health personnel routinely review their performance data and address any challenges with scheduling registry exams with directors.
Closure Date:
6 Ensure the program office reviews registry exam data and continues to work with VA’s Office of Information and Technology to ensure all facilities and veterans are included and properly coded.
Closure Date:
7 Establish procedures for medical facilities to transfer assigned veterans to receive an exam at a closer facility or as otherwise appropriate.
Closure Date:
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| 21-02704-135 | Veterans Prematurely Denied Compensation for Conditions That Could Be Associated with Burn Pit Exposure | Review | ||
1 Take any needed corrective actions on the four errors involving the improperly granted conditions based on burn pit exposure.
Closure Date:
2 Review all denials of compensation claims identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions claimed by eligible veterans to be due to burn pit exposure; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.
3 Review all denials of compensation claims not identified as burn pit claims completed from May 1, 2020, to May 1, 2021, for conditions of bronchial asthma, chronic bronchitis, allergic rhinitis, sleep apnea, and chronic obstructive pulmonary disease submitted by veterans who served where and when burn pits were used even if not specifically cited in the claim; correct any errors identified; and provide certification of completion of the review to the Office of Inspector General.
4 Update the Adjudications Procedures Manual to provide separate and specific guidance for when claims should be considered based on burn pit exposure and proper development for these claims.
Closure Date:
5 Modify the examination request web-based application to add specialty language into medical opinion requests for burn pit exposure claims, to include the contents from the fact sheet for burn pit claims.
Closure Date:
6 Implement a plan to develop controls that review the accuracy of rating decisions going forward to minimize improper denials for burn pit claims, correct any errors identified, and address error trends.
Closure Date:
7 Update training materials and ensure they are consistent with the adjudication procedures manual guidance for developing burn pit exposure claims.
Closure Date:
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| 21-01081-155 | Inadequate Acceptance of Supplies and Services at Regional Procurement Office West Led to $12.8 Million in Questioned Costs | Review | ||
1 Establish controls to ensure contracting officers’ representatives upload required documentation of acceptability of supplies and services to the electronic contracting officer representative file prior to payment.
Closure Date:
2 Establish a requirement and a process for branch chiefs to consistently monitor contract administration documentation.
Closure Date:
3 Assess existing contracts that require an electronic contracting officer representative file and take corrective actions to ensure compliance.
Closure Date:
4 Establish controls to ensure contracting officers create an electronic contracting officer representative file for all contracts requiring a contracting officer’s representative.
Closure Date:
5 Assess existing contracts to ensure contracting officers have completed contracting officer’s representative delegation memorandums, if required.
Closure Date:
6 Establish controls to ensure contracting officers and contracting officer’s representatives have a completed contracting officer’s representative delegation memorandum in the electronic contracting officer representative file, if required.
Closure Date:
7 Establish a quality assurance process to ensure compliance with contract administration requirements for establishing an electronic contracting officer representative file, completing contracting officer’s representative delegation memorandums, and
maintaining acceptance documentation.
Closure Date:
8 Assess whether additional training is needed to clarify officials’ roles and responsibilities for documenting acceptance of supplies and services.
Closure Date:
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| 21-02194-198 | Review of Veterans Health Administration’s Response to a Medication Recall | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health evaluates current guidance regarding the monitoring and reporting of medication recall adverse drug events and makes changes as necessary.
Closure Date:
2 The Under Secretary for Health reviews vulnerabilities in the medication recall process due to variances in Veterans Health Administration medical facility processes and makes changes as necessary.
Closure Date:
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| 22-01137-204 | The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm | National Healthcare Review | ||
1 The Deputy Secretary reviews the process that led to Oracle Cerner’s failure to inform VA of the unknown queue and takes action as indicated.
Closure Date:
2 The Deputy Secretary evaluates the unknown queue technology and mitigation process and takes action as indicated.
Closure Date:
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| 21-02201-200 | Senior Staff Gave Inaccurate Information to OIG Reviewers of Electronic Health Record Training | Administrative Investigation | ||
1 Issue a clarifying communication to the office’s personnel that all staff have a right to speak directly and openly with Office of Inspector General staff without fear of retaliation, and that, irrespective of any processes established to facilitate the flow of information, Electronic Health Record Modernization Integration Office personnel are encouraged to communicate directly with OIG staff when needed to proactively clarify requests and avoid confusion.
Closure Date:
2 Provide clear guidance that the office’s personnel must provide timely, complete, and accurate responses to requests for all data or information without alteration, unless other formats are requested, with full disclosure of the methodology, any data limitations, or other relevant context. This includes prompt OIG access to entire datasets consistent with the Inspector General Act of 1978, as amended.
Closure Date:
3 Determine whether any administrative action should be taken with respect to the conduct or performance of the executive director of Change Management.
Closure Date:
4 Determine whether any administrative action should be taken with respect to the conduct or performance of Change Management’s director for training strategy.
Closure Date:
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| 21-00239-180 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 5: VA Capitol Health Care Network in Linthicum, Maryland | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines the reason for noncompliance, reviews the credentials file, and approves the VA appointment for physicians who had a potentially disqualifying licensure action.
Closure Date:
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| 21-00287-194 | Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders properly identify adverse events as sentinel events when criteria are met and conduct institutional disclosures, as required.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Health Systems Specialist participates on the VISN Systems Redesign Review Advisory Group.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend Facility Surgical Workgroup meetings.
Closure Date:
4 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate all patient transfers.
Closure Date:
5 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
Closure Date:
6 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to receiving facilities during inter-facility transfers.
Closure Date:
7 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
Closure Date:
8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all Employee Threat Assessment Team members complete the required training.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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| 21-02599-156 | Contract Closeout Compliance Needs Improvement at Regional Procurement Offices Central and West | Review | ||
1 Establish procedures for consistent quality assurance reviews to ensure all contract closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, update Veterans Health Administration policies and procedures to provide guidance on conducting and documenting the reviews.
Closure Date:
2 Assess and determine how to effectively distribute contracting officer workload and address imbalances among staff to help ensure contract closeouts are completed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
Closure Date:
3 Clarify the Veterans Health Administration procurement manual to indicate when simplified acquisition procedures closeout processes are to be used and the documentation requirements for each contract closeout step.
Closure Date:
4 Determine whether setting aside specific time weekly to focus on contract administration tasks, such as contract closeout, and using contractors to perform closeout procedures could improve contract closeout compliance.
Closure Date:
5 Ensure the contract files for the 81 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
Closure Date:
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14957