Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00879-118 | VA’s Compliance with the VA Transparency & Trust Act of 2021 | Review | ||
1 Consult with appropriate VA financial and legal officials to determine whether the use of CARES Act funds for the Beaufort National Shrine project violates the Purpose Statute and, if a violation occurred, take the steps necessary to remedy the violation.
Closure Date:
2 Determine the obligations to sustain essential information technology investments, update the obligation schedule as necessary, provide an updated spend plan to Congress, and include this information in future biweekly updates.
Closure Date:
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| 21-00656-110 | Medication Management Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Deputy Secretary ensures that substantiated and unresolved allegations discussed in this report are reviewed and addressed.
Closure Date:
2 The Deputy Secretary ensures medication management issues related to the new electronic health record that are identified subsequent to this inspection be reported to the Office of Inspector General for further analysis.
Closure Date:
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| 21-00781-109 | Care Coordination Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Deputy Secretary ensures that substantiated and unresolved allegations noted in this report are reviewed and addressed.
Closure Date:
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| 21-00781-108 | Ticket Process Concerns and Underlying Factors Contributing to Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Deputy Secretary completes an evaluation of the new electronic health record problem resolution processes and takes action as warranted.
Closure Date:
2 The Deputy Secretary completes an evaluation of the underlying factors of substantiated allegations identified in this report and takes action as warranted.
Closure Date:
3 The Deputy Secretary ensures the electronic health record modernization deployment schedule reflects resolution of the allegations and concerns discussed in this report.
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| 21-00281-100 | Comprehensive Healthcare Inspection of the Salem VA Medical Center in Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that staff monitor and evaluate inter-facility patient transfers as part of VHA’s Quality Management Program.
Closure Date:
2 The Chief of Staff and Associate Director–Patient/Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.
Closure Date:
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| 21-03325-86 | Review of Allegations of Improper Maintenance at VA’s Houston National Cemetery | Review | ||
1 Revise the equipment policy to include provisions and timelines to resume routine activities, such as required preventive maintenance checks, which could be affected by natural disasters or emergencies, such as the COVID 19 pandemic.
Closure Date:
2 Provide an action plan and timeline to repair the headstones or sod in the 65 gravesites the team identified.
Closure Date:
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| 21-02750-63 | Public Disability Benefits Questionnaires Reinstated but Controls Could Be Strengthened | Review | ||
1 Revise the Veterans Benefits Administration’s adjudication procedures manual to clarify and communicate steps that claims processors must take to ensure all certification elements on the publicly available disability benefits questionnaires are provided and are authentic.
Closure Date:
2 Update the Veterans Benefits Administration’s adjudication procedures manual to clarify the intent of guidance involving authenticity, face value, and validation of publicly available disability benefits questionnaires to ensure claims processors evaluate the questionnaires in accordance with evidentiary principles
Closure Date:
3 Implement actions to facilitate claims processors’ understanding of the need to document the evaluation of evidence within benefits entitlement decisions when using publicly available disability benefits questionnaires.
Closure Date:
4 Amend the Veterans Benefits Administration’s adjudication procedures manual to define valid rationale to ensure medical opinions are well supported when deciding entitlement to benefits.
Closure Date:
5 Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.
Closure Date:
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| 21-00280-89 | Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign and Improvement Coordinator tracks facility-level improvement capabilities and projects.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete a final peer review within 120 calendar days from the date it is determined that a peer review is needed, or the Medical Center Director approves an extension request in writing.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff monitor and evaluate inter-facility transfers.
Closure Date:
6 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure transferring providers complete all required elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent prior to patient transfers.
Closure Date:
7 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
8 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings
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 area.
Closure Date:
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| 21-00289-90 | Comprehensive Healthcare Inspection of the James J. Peters VA Medical Center in Bronx, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Peer Review Committee submits a quarterly summary analysis for review by the Medical Executive Committee.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Facility Surgical Workgroup meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Facility Surgical Workgroup reviews surgical deaths and evaluates critical surgical events as required.
Closure Date:
4 The Chief of Staff and Nurse Executive (ADPCS/Chief Nurse Executive) evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
5 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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| 21-01506-76 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers conduct four follow-up visits, either face-to-face or telephonic with documented patient preference, within the required time frame.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures providers collaborate with suicide prevention coordinators when follow-up contact is unsuccessful for high-risk patients.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that employees complete initial suicide risk and intervention training within 90 days of hire and annual suicide prevention refresher training.
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that all facility suicide prevention coordinators complete at least five outreach activities per facility each month.
Closure Date:
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14957