Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-01153-52 | The PACT Act Has Complicated Determining When Veterans’ Benefits Payments Should Take Effect | Review | ||
1 Create a job aid for claims processors on how to determine the correct effective date for PACT Act–related claims.
2 Remove the outdated effective date builder from the Veterans Benefits Administration’s internal job aids page.
Closure Date:
3 Continue updating the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when the Veterans Benefits Administration receives an intent to file.
Closure Date:
4 Update the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when a veteran’s service connection is based on a toxic exposure risk activity.
Closure Date:
5 Evaluate PACT Act refresher training by monitoring the results to assess the effectiveness of the training.
Closure Date:
6 Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.
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| 24-02356-58 | A Prohibited Default in the Clinically Indicated Date Field Limited Some Veterans’ Eligibility for Community Care at the Omaha VA Medical Center in Nebraska | Review | ||
1 Issue a memorandum that clarifies that automatically prepopulating the clinically indicated date field of a consult is prohibited (barring officially recognized exceptions) and that it should be entered manually.
Closure Date:
2 Determine whether any administrative action should be taken with respect to the conduct of the medical facility director and the chief of staff of the Omaha VA Medical Center.
3 Direct the medical facility director to educate and train those involved with consults on the process, including how to customize the clinically indicated date to reflect the date of care agreed to by the provider and the veteran. The training should be mandatory, its contents should comply with national policy, and its frequency should be determined by the medical facility director.
4 Assess the actions the medical facility has taken to review the consults that were potentially affected by the 29-day default in the clinically indicated date field and ensure veterans received the care they needed.
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| 24-00595-93 | Healthcare Facility Inspection of the VA Western Colorado Healthcare System in Grand Junction | Healthcare Facility Inspection | ||
1 The OIG recommends executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.
2 The OIG recommends executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.
Closure Date:
3 The OIG recommends executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.
4 The OIG recommends executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.
5 The OIG recommends executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.
6 The OIG recommends executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patient’s care.
Closure Date:
7 The OIG recommends Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.
8 The OIG recommends executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.
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| 22-02369-48 | Independent Audit Report on a Transportation Company’s Billing Practices Under a VA Healthcare System Contract | Audit | ||
1 Seek the opinion of the Office of General Counsel on whether the identified potential overbillings could or should be recouped.
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| 24-00295-49 | VHA Should Improve Monitoring of Underground Storage Tanks to Minimize Environmental and Health Risks at VA Medical Facilities | Audit | ||
1 As a part of the annual certification process of the Capital Asset Inventory, the executive director of the Office of Asset Enterprise Management should provide guidance on underground storage tank entries to ensure these assets are recorded with consistent identifying terminology in asset identification fields and with the appropriate real property predominant use code: code 40, “storage (other than buildings).”
2 Ensure Veterans Integrated Service Network officials fulfill their oversight responsibilities found in Veterans Health Administration Directive 1811 requiring VA medical facilities maintain a current inventory of underground storage tanks, inclusive of all associated equipment and component levels.
3 Ensure the assistant under secretary for health for support updates the responsibility section in Veterans Health Administration Directive 7707 to ensure that the responsibilities of VA medical facility directors include appropriate designation of staff and training for environmental regulatory requirements.
4 Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 to ensure facility compliance with federal, state, and local codes, laws, and regulations—including monitoring and addressing underground storage tank alarms promptly to confirm a release has not occurred.
5 Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 for work order (unplanned corrective maintenance) tracking from creation through completion in the approved maintenance management system—to include underground storage tank and associated component-level equipment failures or deficiencies identified in regulatory agencies’ inspections.
6 Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling responsibilities in Veterans Health Administration Directive 7707 to ensure regulatory compliance deficiencies are promptly reviewed, corrective actions are developed, and issues are tracked through completion to satisfactorily address environmental compliance.
7 Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling their oversight responsibilities found in Veterans Health Administration Directive 7707 to ensure all required federal, state, and local regulatory agencies’ inspections of underground storage tanks are recorded in the Veterans Health Administration issue brief tracking system.
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| 24-00611-82 | Healthcare Facility Inspection of the VA Memphis Healthcare System in Tennessee | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety between the parking garage and bed tower entrance until completion.
Closure Date:
2 The OIG recommends facility leaders improve doorway safety at the bed tower entrance by placing sensors on the two power-assisted doors, reactivating the revolving door, and monitoring doorway safety until completion.
Closure Date:
3 The OIG recommends the Director ensures staff monitor the emergency exit near the laboratory to make sure the door remains unlocked and operational.
Closure Date:
4 The OIG recommends the Director assesses the facility’s tactile signs (braille) and auditory cues and implements a plan to address the deficient areas.
Closure Date:
5 The OIG recommends facility leaders evaluate the toxic exposure screening process and implement a plan to ensure staff complete the screenings.
Closure Date:
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| 23-02350-95 | Inadequate Governance Structure and Identification of Chief Mental Health Officers’ Responsibilities | National Healthcare Review | ||
1 The Under Secretary for Health clarifies Veterans Integrated Service Network staffing requirements, including mandatory and discretionary positions.
2 The Under Secretary for Health ensures the use of the standardized Veterans Integrated Service Network core organizational chart to promote clarity of the Chief Mental Health Officer position and reporting structure.
3 The Under Secretary for Health considers standardization of the Veterans Integrated Service Network Chief Mental Health Officer functional statement to reflect role responsibilities.
4 The Under Secretary for Health ensures the alignment of the Veterans Integrated Service Network Chief Mental Health Officer performance plan with the functional statement.
5 The Under Secretary for Health defines the Veterans Integrated Service Network Chief Mental Health Officer role authority to enhance governance efficiency and effectiveness of mental health services.
Closure Date:
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| 24-03692-76 | Review of VA’s $2.9 Billion Supplemental Funds Request for FY 2024 to Support Veterans’ Benefits Payments | Review | ||
1 Develop comprehensive management controls with clear roles and responsibilities at each level of the Veterans Benefits Administration to ensure effective oversight of mandatory accounts and the timely communication of any potential budgetary shortfalls.
2 Ensure the Office of Financial Management develops procedures to incorporate all available budgetary resources, as reported on the SF-133s, in its calculations for the status of funds reports for transparent communication to internal and external stakeholders.
3 Institutionalize monthly fiscal reviews between the Office of Financial Management and program offices to routinely assess performance and cost drivers that may affect the status of available funds.
4 Institutionalize monthly fiscal reviews between the VA Office of Budget and the Veterans Benefits Administration Office of Financial Management to routinely assess performance and cost drivers that may affect the status of available funds.
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| 24-03127-66 | The Causes and Conditions That Led to a $12 Billion Supplemental Funding Request | Review | ||
1 Review the Veterans Health Administration’s current methods, assumptions, and approaches used to project medical care budget needs in the annual President’s Budget to identify any gaps in the process or data limitations, and develop and implement a plan to strengthen the process.
2 Establish and implement a plan to review current processes and procedures for involving program offices and pertinent subject matter experts in developing the Enrollee Health Care Projection Model inputs for specific areas such as community care, staffing, pharmacy services, and prosthetics services, and formalize the expectations of their involvement in this process through guidance or protocols.
3 Develop and implement an approach to estimate medical care personnel needs and costs to increase the accuracy and reliability of information included in the annual President’s Budget.
4 Institutionalize a regular cycle of at least quarterly fiscal reviews among assistant under secretaries for health, network directors, and program offices that routinely assess key cost drivers and other areas of concern, such as staffing, community care growth, and local initiatives.
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| 24-02232-87 | Care Failures for a Patient with Alcohol Withdrawal at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director directs nursing leaders to review records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders to confirm that medical intensive care unit nurses document Clinical Institute Withdrawal Assessment of Alcohol Scale scores consistent with patient’s documented behavior and symptoms and takes actions to address any deficiencies that are identified.
2 The Hampton VA Medical Center Director confirms that nursing leaders complete review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders to determine the extent with which administration of medication is in adherence with the protocol and take actions to address any deficiencies that are identified.
3 The Hampton VA Medical Center Director ensures that a review of records of medical intensive care unit patients with Clinical Institute Withdrawal Assessment of Alcohol Scale protocol orders is completed by nursing leaders to (a) assess the degree of compliance with completing Clinical Institute Withdrawal Assessment of Alcohol Scale assessments based on the last assessment score, as outlined in the protocol, and (b) review the actual time Clinical Institute Withdrawal Assessment of Alcohol Scale is completed in comparison to the time it is documented in the electronic health records to identify significant delays, if any, and based on analysis of findings, takes action to address deficiencies that are identified.
4 The Hampton VA Medical Center Director works with the facility Chief of Staff to ensure medical intensive care unit providers have reviewed a clinical practice guideline specific to management of alcohol withdrawal from an accredited source, such as The American Society of Addiction Medicine.
Closure Date:
5 The Hampton VA Medical Center Director confirms completion of a review to assess the current process for communicating unit-based medication shortages and how staff can confirm the availability of shortage medications when use of the medication is key to the patient’s treatment and updates the process as warranted.
6 The Hampton VA Medical Center Director ensures that the facility’s Alcohol Withdrawal Management standard operating procedure aligns with requirements for a standard operating procedure outlined in Veterans Health Administration Notice 2024-09.
7 The Hampton VA Medical Center Director confirms that training requirements specified in Veterans Health Administration Notice 2024-09 are completed, training attendance is tracked, and a process is in place to monitor accurate and consistent use of the alcohol withdrawal scale identified in the facility standard operating procedure.
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