Recommendations
2111
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00982-147 | The Emergency Department Construction Project at the Audie L. Murphy Memorial Veterans’ Hospital in San Antonio, Texas, Did Not Follow VA and Industry Equipment Design Standards | Review | ||
1 Ensure processes and guidance are in place for the director of the Office of Construction and Facilities Management to provide appropriate oversight and management over minor construction projects consistent with the authority and responsibilities described in 38 U.S.C. § 312A.
2 Revise the Veterans Health Administration directive on minor construction projects to incorporate 38 U.S.C. § 312A requirements and develop a review process for confirming compliance with the Office of Construction and Facilities Management’s guidance and any applicable industry standards.
3 Review the Audie L. Murphy emergency department exam and fast-track rooms for compliance with applicable design and equipment standards and provide any recommendations to the executive director of the South Texas Veterans Health Care System.
4 Review an assessment by the Office of Construction and Facilities Management of the Audie L. Murphy’s emergency department for compliance with design and equipment requirements to determine what changes, if any, are necessary and take appropriate corrective action.
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| 25-00191-212 | Healthcare Facility Inspection of the VA Jackson Healthcare System in Mississippi | Healthcare Facility Inspection | ||
1 The facility Director ensures staff review primary care panel sizes and capacity levels to ensure they are accurate.
Closure Date:
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| 24-01676-153 | Improved Oversight of VHA’s Nonexpendable Equipment Is Needed | Audit | ||
1 Reassess and clarify physical inventory requirements for equipment in medical facilities to ensure they are consistent with and meet the intent of VA Directive 7002.
2 Ensure that facility directors require custodial officers to regularly review nonexpendable inventory to determine whether the equipment is required and take appropriate action.
3 Ensure medical facility directors review inventory list compliance data to identify noncompliant services and implement a process to resolve noncompliance.
4 Ensure the Veterans Health Administration’s Procurement and Logistics Office, in coordination with VA’s Office of Acquisition and Logistics, regularly monitors inventory compliance data to identify and communicate with noncompliant facilities to proactively address delinquent inventories.
5 Require medical facilities to use a standardized report of survey dashboard to centrally report all lost, stolen, or damaged items.
6 Require medical facility directors to review inventory compliance and establish a process to ensure noncompliant equipment—to include equipment identified in this audit—is reported as lost, stolen, or damaged within required time frames.
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| 24-02295-155 | Facilities Need to Fully Implement VHA’s Strategic Planning and Request Process for Nonexpendable Medical Equipment | Audit | ||
1 Reiterate through formal communication that facilities and regional Veterans Integrated Service Networks are required to fully implement and use the Strategic Equipment Planning Guide and Enterprise Equipment Request process for equipment planning and approval and develop a system to monitor compliance and verifying facilities are using the process as required.
2 Ensure relevant staff complete training on the Strategic Equipment Planning Guide and Enterprise Equipment Request process that explains user roles and responsibilities.
Closure Date:
3 Ensure facilities define and assign Strategic Equipment Planning Guide and Enterprise Equipment Request user roles and responsibilities as applicable.
4 Reiterate through the formal communication advised in recommendation 1 that the Strategic Equipment Planning Guide and Enterprise Equipment Request process are required for all equipment planning and approval—and clearly define whether there are any exceptions.
Closure Date:
5 Specify when and which equipment purchases require review and approval by additional subject matter experts.
Closure Date:
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| 24-00758-138 | Not All VA Disability Compensation Examiners Completed Training Before Providing PACT Act Medical Opinions | Review | ||
1 Ensure a disability compensation examiner who has completed PACT Act training provides an independent assessment and medical opinion for the 29 VHA and five VBA nonpresumptive PACT Act opinions identified by the Office of Inspector General that were provided before completing PACT Act training, and readjudicate the claims as needed.
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| 24-01757-146 | VISN 12 Needs to Improve How It Administers the Veterans Community Care Program | Review | ||
1 Establish and use agreements with other VA medical facilities to help identify and schedule direct care when services are unavailable at a veteran’s local VA facility.
Closure Date:
2 At least annually, emphasize to schedulers the proper methods (including the use of codes) to document when veterans opt out of community care.
Closure Date:
3 Require the medical facility director at the Jesse Brown VA Medical Center in Chicago to make sure veterans who request mental health services are assessed for community care and informed of all potential care options.
Closure Date:
4 Require medical facility directors in Veterans Integrated Service Network 12 to review and process consults initiated in the first quarter of fiscal year 2024 that remain in a pending, active, or scheduled status.
Closure Date:
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| 23-03768-204 | Former Acquisition Academy Executive Violated Ethical Standards and VA Policy | Administrative Investigation | ||
1 The principal executive director of the Office of Acquisition, Logistics, and Construction considers whether any additional training or other measures are necessary with respect to reporting the wrongdoing of a supervisor and the acceptance of free meals and drinks by VA employees during the February 2023 site visit.
2 The principal executive director of the Office of Acquisition, Logistics, and Construction determines whether any additional guidance, training, or oversight is needed with respect to ensuring VA employees do not improperly solicit sponsorships for VA events that do not primarily benefit veterans.
3 VA’s designated agency ethics official determines whether any additional steps need to be taken in connection with Ms. Dawson’s 2023 public financial disclosure based on the findings of this report.
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| 25-00189-199 | Healthcare Facility Inspection of the VA Texas Valley Coastal Bend Healthcare System in Harlingen | Healthcare Facility Inspection | ||
1 Facility leaders identify barriers to providers completing toxic exposure screenings and implement actions to ensure providers complete screenings within 30 days of initiation.
Closure Date:
2 Facility leaders ensure each service has a service-level workflow for test result communication that is consistent with VHA requirements.
Closure Date:
3 The Director ensures the Chief of Staff attends Peer Review Committee meetings.
Closure Date:
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| 25-00400-189 | Deficiencies in Quality of Care and the Root Cause Analysis Process at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 The Overton Brooks VA Medical Center Director conducts a comprehensive review of the patient’s hospitalization and takes action as indicated, including quality management improvement processes such as a peer review.
Closure Date:
2 The Overton Brooks VA Medical Center Director ensures medical staff recognize the importance of obtaining hospitalized patients’ non-VA medical records and assesses the current processes for obtaining non-VA medical records, identifies any barriers to completion, and takes action as warranted.
3 The Overton Brooks VA Medical Center Director assesses the application of the one-to-one observation policy and practices at the facility, and takes action as warranted.
Closure Date:
4 The Overton Brooks VA Medical Center Director reviews interim behavioral patient record flag processes to ensure implementation of safety strategies for staff and patients, and takes action as warranted.
5 The Overton Brooks VA Medical Center Director evaluates whether documentation of patient and patient-related behavioral events are reflected accurately in the electronic health record to facilitate continuity of care and communication among medical staff and takes action as necessary.
Closure Date:
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| 24-00765-184 | Pharmacy Automated Dispensing Cabinets Need Improved Monitoring for Accountability over High-Risk Medications | Review | ||
1 Confirm that medical facility directors develop local guidance on using automated dispensing cabinets in accordance with VHA Directive 1108.21 (and any revisions to this directive) and that facilities comply with that local guidance.
2 Require Pharmacy Benefits Management Services to revise VHA Directive 1108.21 to include routine monitoring for the use of generic information as a requirement in facility-level guidance for automated dispensing cabinets.
3 Ensure, in coordination with the controlled substance coordinator, or appropriate designee, and Veterans Integrated Service Networks, that reports detailing cabinet transactions for controlled substances removed using generic information are reviewed as part of required controlled substance inspections.
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