Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-00236-44 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 8: VA Sunshine Healthcare Network in St. Petersburg, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials files and approve the VA appointments of physicians who had potentially disqualifying licensure actions.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the Lead Women Veterans Program Manager completes yearly site visits at each facility within the Veterans Integrated Service Network.
Closure Date:
| ||||
| 21-00279-54 | Comprehensive Healthcare Inspection of the Charles George VA Medical Center in Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure all patient transfers are monitored and evaluated.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that referring providers complete all required elements of the VA Inter-facility Transfer Form or facility-defined equivalent prior to patient transfers.
Closure Date:
3 The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services/Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that Employee Threat Assessment Team members complete the required training.
Closure Date:
| ||||
| 20-03351-08 | MISSION Act Market Assessments Contain Inaccurate Specialty Care Workload Data | Audit | ||
1 The OIG recommended that the acting under secretary for health perform additional analyses to ensure materially accurate specialty care workload data are used to implement the Asset and Infrastructure Review Commission recommendations.
Closure Date:
| ||||
| 21-01804-56 | Vet Center Inspection of Pacific District 5 Zone 2 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons for missing and incomplete clinical quality reviews, remediation plans, and resolution of deficiencies; ensures completion; and monitors compliance.
Closure Date:
2 The District Director evaluates the process for resolution of clinical quality review deficiencies and initiates action as necessary.
Closure Date:
3 The District Director determines reasons for missing and incomplete administrative quality reviews, remediation plans, and resolution of deficiencies; ensures completion; and monitors compliance.
Closure Date:
4 The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.
Closure Date:
5 The District Director ensures intake assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
6 The District Director ensures lethality risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
Closure Date:
7 The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including reasons completion dates are not visible in RCSnet and ensures compliance with standards for timely completion of intake assessments and lethality risk assessments.
Closure Date:
8 The District Director ensures clinical staff consult and coordinate care with the shared support VA medical facility for clients with high risk for suicide flag placement and monitors compliance across all zone vet centers.
Closure Date:
9 The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
10 The District Director ensures clinical staff consult with the vet center director, external clinical consultant, or suicide prevention coordinator following a lethality status change as required and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director, in collaboration with the support VA medical facility clinical or administrative liaison, determines the reasons for noncompliance with staff participation on mental health councils at the Fresno, High Desert, Honolulu and Santa Cruz County Vet Centers, and takes action as required.
Closure Date:
13 The District Director determines reasons for noncompliance with completing and tracking the required four hours of external clinical consultation per month, ensures that Vet Center Directors have processes to track consultation hours, and monitors compliance at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers.
Closure Date:
14 The District Director determines reasons for noncompliance with staff supervision provided by the Vet Center Directors at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
15 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
16 The District Director determines reasons why trainings were not completed at the Fresno, High Desert, Honolulu, and Santa Cruz County Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
17 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the High Desert, Honolulu, and Santa Cruz County Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards requirements.
Closure Date:
| ||||
| 21-01038-49 | Deficiencies in a Patient’s Lung Cancer Screening, Renal Nodule Follow-Up, and Prostate Cancer Surveillance at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Medical Center Director reviews primary care and pulmonology processes to ensure patients with high-risk factors for lung cancer receive screening and follow-up care and monitors compliance.
Closure Date:
2 The VA Southern Nevada Healthcare System Medical Center Director implements processes to ensure that patients with abnormal radiology findings have appropriate follow-up and monitors compliance.
Closure Date:
3 The VA Southern Nevada Healthcare System Medical Center Director ensures that providers follow the guidelines for surveillance for patients who have undergone prostatectomy.
Closure Date:
4 The VA Southern Nevada Healthcare System Medical Director reviews primary care providers’ copy and paste practices, implements processes to ensure a current plan of care is documented in the electronic health record, and monitors compliance.
Closure Date:
5 The VA Southern Nevada Healthcare System Medical Center Director reviews the complaint reporting and responding processes, ensures complaints are addressed in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
| ||||
| 19-07812-29 | Inadequate Oversight of VHA’s Home Oxygen Program | Audit | ||
1 The OIG recommended that the under secretary for health implement comprehensive guidance for staff who schedule home oxygen consults that includes processes for working with patients who do not or are unable to attend scheduled reevaluations, and for determining how and when to discontinue home oxygen services when appropriate.
Closure Date:
2 The OIG recommended that the under secretary for health update guidance to include any exceptions to the scheduling time frame based on the type of home oxygen services patients are prescribed.
Closure Date:
3 The OIG recommended that the under secretary for health update policy to assign oversight responsibility for ensuring the number of home or telehealth visits outlined in guidance is conducted.
Closure Date:
4 The OIG recommended that the under secretary for health require the network contracting offices to provide oversight so that (1) contracting officers ensure vendor performance evaluations and quality assurance reports are completed and documented in the electronic contract management system, and (2) contracting officers comply with requirements when designating contracting officer’s
representatives.
Closure Date:
5 The OIG recommended that the under secretary for health clearly communicate processes or tools that staff should use to achieve the contract monitoring requirements outlined in the Federal Acquisition Regulation.
Closure Date:
6 The OIG recommended that the under secretary for health ensure facilities in Veterans Integrated Service Network 7 review orders that were paid for home oxygen services without an awarded contract and submit a request for ratification to the head of the contracting activity for any unauthorized commitments.
Closure Date:
| ||||
| 21-00960-17 | Financial Efficiency Review of the Marion VA Medical Center in Illinois | Financial Inspection | ||
1 Develop a plan to routinely provide updates when changes in stock levels are anticipated and work with the prime vendor to address having adequate stock to meet orders.
Closure Date:
2 Ensure logistics staff and contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance concerns and challenges.
Closure Date:
3 Implement a process to routinely check the formulary for additions and update the ordering system to reflect the prime vendor as the source for purchasing newly added supplies.
Closure Date:
4 Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
Closure Date:
5 Ensure healthcare system finance office staff are made aware of policy requirements and the responsible finance office conducts reviews on all open obligations as required by VA Financial Policies and Procedures, vol. II, chap. 5, “Obligations Policy,” January 2018.
Closure Date:
6 Promote veterans’ use of the Consolidated Mail Outpatient Pharmacy.
Closure Date:
7 Educate non-VA providers on prescribing lower-cost drugs.
Closure Date:
8 Implement Veterans Integrated Service Network 15 recommendations to ensure the cost-saving initiatives are implemented, tracked, and monitored to achieve identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
| ||||
| 21-00942-16 | Financial Efficiency Review of the Eastern Oklahoma VA Health Care System | Financial Inspection | ||
1 The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure finance office staff are made aware of policy requirements and reviews are conducted on all open obligations as required by VA Financial Policies and Procedures, vol. 2, chap. 5, “Obligations Policy,” January 2018.
Closure Date:
2 The OIG recommended the director of contracting for Network Contracting Office 19, VA Rocky Mountain Network, develop checks on the successful completion of quarterly audits of the purchase card program as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
Closure Date:
3 The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interests of the government.
Closure Date:
4 The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
Closure Date:
5 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop measures to confirm completed VA Form 0242 submissions are accurate and updated for all cardholders.
Closure Date:
6 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop formalized processes for achieving identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
7 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
Closure Date:
8 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to complete facility based inventory audits of noncontrolled drug line items in compliance with VHA policy.
Closure Date:
9 The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish measures to improve compliance with the nonformulary request process.
Closure Date:
| ||||
| 19-09592-262 | Improvements Needed to Ensure Final Disposition of Unclaimed Veterans’ Remains | Review | ||
1 The OIG recommended the assistant secretary for the Office of Enterprise Integration designate a senior accountable official or program office for the full scope of benefits and services provided on behalf of deceased veterans whose remains are unclaimed. This official or office should be charged with ensuring that VA’s benefits and services for unclaimed veterans comply with applicable federal enterprise risk management and internal control standards.
Closure Date:
2 The OIG recommended the assistant secretary for the Office of Enterprise Integration conduct a program evaluation of all VA benefits and services for deceased veterans whose remains are unclaimed in compliance with applicable laws and VA regulations. This evaluation should consider the extent to which existing law requires VA to conduct outreach on behalf of deceased veterans whose remains are unclaimed. This evaluation should also ensure the benefits and services are assigned to the appropriate VA program offices and the offices are given authority to administer these programs.
Closure Date:
3 The OIG recommended the assistant secretary for the Office of Enterprise Integration coordinate and implement data sharing agreements with other agencies or organizations with records of deceased veterans whose remains are unclaimed or veterans not included in VA databases.
Closure Date:
4 The OIG recommended the assistant secretary for the Office of Enterprise Integration determine eligibility and take action to facilitate dignified burials for these persons with unclaimed remains whose records the OIG referred to VA.
Closure Date:
5 The OIG recommended the assistant secretary for the Office of Enterprise Integration develop a comprehensive estimate of the number of deceased veterans whose remains are unclaimed awaiting burial, including those held at locations other than funeral homes.
Closure Date:
6 The OIG recommended the assistant secretary for management and chief financial officer implement controls for payments made to individual payees or other entities on behalf of deceased veterans whose remains are unclaimed that can be cross referenced across current VA payment systems and ensure that staff involved with issuing payments are trained in the correct use of these controls.
Closure Date:
7 The OIG recommended the under secretary for benefits implement monitoring mechanisms, procedures, and recurring training for VA regional office directors on their responsibilities for facilitating burials for deceased veterans whose remains are unclaimed.
Closure Date:
8 The OIG recommended the under secretary for benefits require points of contact for indigent and unclaimed veterans outreach to regularly complete the outreach functions listed in VA Manual 27 1, chapter 11. VBA should ensure points of contact receive recurring training in these tasks and implement ongoing compliance activities.
Closure Date:
9 The OIG recommended the under secretary for health direct VHA leadership to assess the extent to which personnel in the former VHA Office of Operations and Management and the VHA Office of Member Services were not performing required oversight activities and take appropriate action.
Closure Date:
10 The OIG recommended the under secretary for memorial affairs
implement system indicators in NCA systems to show when veterans’ remains are unclaimed without relying on a manually updated spreadsheet. These system indicators should enable tracking mechanisms to ensure required follow ups are performed on completed burial eligibility determinations without a scheduled interment and identify repeat burial eligibility requests.
Closure Date:
11 The OIG recommended the under secretary for memorial affairs
in coordination with the Secretary’s Center for Strategic Partnerships, assess options for providing a suitable casket or urn to a deceased veteran whose remains are unclaimed rather than a monetary reimbursement.
Closure Date:
| ||||
| 20-04219-07 | Follow-Up Review of the Accuracy of Special Monthly Compensation Housebound Benefits | Review | ||
1 Review all active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
Closure Date:
2 Implement a plan to conduct ongoing periodic reviews of completed active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
Closure Date:
3 Update the special monthly compensation housebound training to include guidance on and examples of statutory, housebound in fact, individual unemployability, and extraschedular criteria, and monitor the effectiveness of the training.
Closure Date:
4 Create a system enhancement to limit the statutory special monthly compensation housebound validation warning to trigger only when statutory housebound criteria are met but not addressed.
Closure Date:
5 Create a system enhancement to prohibit rating veterans service representatives from bypassing statutory housebound validation warnings without taking action or providing justification.
Closure Date:
6 Correct all processing errors on cases identified by the review team and report the results to the OIG.
Closure Date:
| ||||
14957