Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-02125-132 | Purchases of Smartphones and Tablets for Veterans’ Use during the COVID-19 Pandemic | Review | ||
1 Establish a realistic goal for days in storage along with a process for closely monitoring days in storage and taking corrective actions when the goal is not met.
Closure Date:
2 Perform a cost-benefit analysis in conjunction with VA contracting officials and the contractor to determine whether a new process can be implemented that initiates the data plan when a device is issued to the veteran or otherwise reduces unused plan costs.
Closure Date:
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| 21-02209-147 | Inadequate Discharge Coordination for a Vulnerable Patient at the Portland VA Medical Center in Oregon | Hotline Healthcare Inspection | ||
1 The VA Portland Health Care System Director considers adding the requirement to document family contacts in patients’ electronic health records in Portland VA Medical Center Policy 11-11, Discharge Planning, and ensures that staff document contact with family members, including notification of discharge, when applicable.
Closure Date:
2 The VA Portland Health Care System Director ensures a review of the Emergency Department social worker’s care coordination of the patient and takes action as warranted.
Closure Date:
3 The VA Portland Health Care System Director considers requiring Privacy Office staff to communicate the specific missing element(s) when returning a release of information request.
Closure Date:
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| 21-00291-136 | Comprehensive Healthcare Inspection of the VA Finger Lakes Healthcare System in Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete suicide safety plan training prior to developing suicide safety plans.
Closure Date:
2 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of VHA’s Quality Management Program.
Closure Date:
3 The Associate Director for Patient and Nursing Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
4 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required training.
Closure Date:
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| 21-01712-144 | Deficiencies in a Behavioral Health Provider’s Documentation and Assessments, and Oversight of Nurse Practitioners at the VA Pittsburgh Healthcare System in Pennsylvania | Hotline Healthcare Inspection | ||
1 The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment practices related to Patient 8’s suicide and homicide risk and Recovery Engagement and Coordination for Health – Veterans Enhanced Treatment status; and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.
Closure Date:
2 The VA Pittsburgh Healthcare System Director ensures a comprehensive review of the Behavioral Health Nurse Practitioner’s assessment and documentation practices including suicide risk assessments, assessment of antipsychotic medication health factors and side effects, informed consent for off-label medication use, resolution of rule-out diagnoses, and use of copy and paste, and provides training as needed.
Closure Date:
3 The VA Pittsburgh Healthcare System Director aligns VA Pittsburgh Healthcare System Memorandum TX-154, Use of Psychopharmacologic Agents, December 20, 2018, with leaders’ expectations for the assessment and documentation of abnormal involuntary movements and metabolic problems for patients prescribed an antipsychotic medication.
Closure Date:
4 The VA Pittsburgh Healthcare System Director makes certain that behavioral health managers verify that all elements of the behavioral health nurse practitioner ongoing professional practice evaluation are reviewed.
Closure Date:
5 The VA Pittsburgh Healthcare System Director ensures a comprehensive review of managers’ oversight of behavioral health nurse practitioners’ ongoing professional practice evaluations and consults with the appropriate Human Resources and General Counsel Offices to determine whether personnel action is warranted and takes action, as appropriate.
Closure Date:
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| 21-02437-120 | Processing of Post-9/11 GI Bill School Vacation Breaks Affects Beneficiary Payments and Entitlement | Audit | ||
1 The acting under secretary for benefits updates the School Certifying Official Handbook and considers other training aids to ensure how to calculate and report vacation breaks is clearly detailed.
Closure Date:
2 The acting under secretary for benefits develops and implements procedures for claims examiners to verify that all consecutive days are included in enrollments flagged for manual processing containing reported vacation breaks in the remarks section.
Closure Date:
3 The acting under secretary for benefits obtains amended enrollments from school certifying officials to correct vacation break reporting errors identified during this review and take remedial action when appropriate.
Closure Date:
4 The acting under secretary for benefits applies data analysis and record matching to identify enrollments with possible vacation break reporting errors made by school certifying officials, or processing errors by claims examiners.
Closure Date:
5 The acting under secretary for benefits includes in the development of the new automated system fields for vacation breaks to eliminate the need for manual processing.
Closure Date:
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| 19-08364-140 | Facility Leaders’ Response to Inappropriate Mental Health Provider-Patient Relationships at the VA Illiana Health Care System in Danville, Illinois | Hotline Healthcare Inspection | ||
1 The Veteran Integrated Service Network 12 Director evaluates processes that affected facility supervisors’ initial efforts to identify and address facility mental health providers’ inappropriate relationships and takes actions as necessary.
Closure Date:
2 The VA Illiana Health Care System Director reviews the process for reporting providers to state licensing boards or state certification boards and makes appropriate changes as deemed necessary to ensure timely reporting.
Closure Date:
3 The VA Illiana Health Care System Director reviews Patient C’s care to determine if there was an adverse event and if so, whether institutional disclosure is warranted
Closure Date:
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| 21-03916-103 | Atlanta VA Health Care System’s Unopened Mail Backlog with Patient Health Information and Community Care Provider Claims | Review | ||
1 The director of VISN 7 ensures the Atlanta VA Health Care System develops and implements a plan for the routine proper and prompt processing of mail. That plan should include adequate staffing of the mailroom and sufficient training for mailroom personnel.
Closure Date:
2 The director of VISN 7 assists the Atlanta VA Health Care System in taking steps when appropriate to recoup money owed from expired checks that were identified in the mail backlog.
Closure Date:
3 The under secretary for health assess the negative effects of this mail backlog on veterans, community care providers, and other parties, and where possible take steps to remedy those effects.
Closure Date:
4 The under secretary for health determines if unprocessed mail backlogs exist at other VA medical facilities.
Closure Date:
5 The under secretary for health develops procedures and controls to make certain that medical facility personnel taking over POM on-site mail processing have the necessary resources and expertise to accomplish this work accurately and within prescribed timelines.
Closure Date:
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| 21-02889-134 | The Electronic Health Record Modernization Program Did Not Fully Meet the Standards for a High-Quality, Reliable Schedule | Audit | ||
1 The executive director of the Electronic Health Record Modernization Program Management Office complies with internal guidance and ensures the development of an integrated master schedule for the Electronic Health Record Modernization program that complies with standards adopted from GAO for scheduling.
2 The executive director of the Electronic Health Record Modernization Program Management Office takes action to improve stakeholder coordination in the development of the program schedules to ensure activities from all relevant VA entities are included.
3 The executive director of the Electronic Health Record Modernization Program Management Office develops procedures for when and how staff should perform an initial schedule risk analysis for the program and conduct periodic updates as needed.
4 The executive director of the Electronic Health Record Modernization Program Management Office ensures consistency between contract language and program office plans or other guidance identifying the entity or individuals responsible for developing and maintaining the program’s work breakdown structure and integrated master schedule.
5 The executive director of the Electronic Health Record Modernization Program Management Office evaluates the contract requirements for schedule management and modifies as needed to ensure clear roles and expectations for further development and maintenance of the program’s integrated master schedule.
Closure Date:
6 The executive director of the Electronic Health Record Modernization Program Management Office complies with the Federal Acquisition Regulation and issue guidance to accept deliverables not separately priced before invoice payment.
Closure Date:
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| 21-00836-124 | Additional Actions Can Help Prevent Benefits Payments from Being Sent to Deceased Veterans | Review | ||
1 The under secretary for benefits implements procedures to identify failed automated weekly death matches and demonstrate progress towards processing all failed matches.
Closure Date:
2 The under secretary for benefits implements a process to review the social security number verification program and demonstrate progress towards ensuring the accuracy of social security numbers in VBA’s electronic systems.
Closure Date:
3 The under secretary for benefits implements an intra-agency data-sharing process with the Veterans Health Administration and demonstrate progress in obtaining information on veterans’ deaths.
Closure Date:
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| 21-00294-128 | Comprehensive Healthcare Inspection of the Syracuse VA Medical Center in New York | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director determines the reasons for noncompliance and makes certain that leaders identify adverse events as sentinel events when criteria are met.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that leaders conduct institutional disclosures for all sentinel events.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator consistently participates in Veterans Integrated Service Network Systems Redesign Review Advisory Group meetings.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group meets monthly and core members consistently attend meetings.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group analyzes efficiency and utilization metrics and evaluates critical surgical events.
Closure Date:
6 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
7 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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14957