Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-02067-82 | The Medical Disability Examination Office Needs to Better Monitor Mileage Requirements for Contract Exams | Review | ||
1 Implement a process to monitor and demonstrate progress to assess vendors’ compliance with contractual mileage and travel reimbursement requirements.
Closure Date:
2 Collaborate with vendors to ensure portals include proper documentation of express consent.
Closure Date:
3 Collaborate with vendors to ensure mileage reimbursement information is available in vendor portals.
Closure Date:
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| 21-03313-96 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 9: VA MidSouth Healthcare Network in Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The Network Director evaluates and determines additional reasons for noncompliance and submits a Comprehensive Environment of Care compliance report to the Environment of Care Committee annually.
Closure Date:
2 The Network Director evaluates and determines additional reasons for noncompliance and makes certain the Environment of Care Committee reviews Comprehensive Environment of Care Compliance and Assessment Tool data at least quarterly.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Emergency Management Committee conducts an annual review of the Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement, and documents it in writing.
Closure Date:
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| 22-02604-74 | Audie L. Murphy Memorial Veterans’ Hospital Missed Opportunities to Distribute Excess Ventilators during the COVID-19 Pandemic | Review | ||
1 Document a methodology for determining the number of ventilators required by the Audie L. Murphy Memorial Veterans’ Hospital to fulfill its mission and provide care during routine and emergency operations.
Closure Date:
2 Determine whether the remaining ventilators are required to support the hospital’s mission. If excess ventilators are identified, perform procedures to turn them in for reassignment, reutilization, or disposal in accordance with VA Handbook 7002.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $2,500,000
Total: $2,500,000
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| 21-03133-48 | Office of Emergency Management Has Not Deployed a Functional Last-Resort Emergency Communications System | Audit | ||
1 Ensure medical facilities monitor resilient high-frequency radio network training and staffing levels and maintain enough trained staff to operate the resilient high-frequency radio network.
Closure Date:
2 Ensure that the appropriate stakeholders know the program office responsible for the resilient high-frequency radio network and understand the roles and responsibilities for the Veterans Health Administration’s Resilient High-Frequency Radio Network program.
Closure Date:
3 Finalize the Veterans Health Administration High-Frequency Radio Operations Plan.
Closure Date:
4 If additional resilient high-frequency radio network equipment is purchased, work with the contracting officer to provide guidance to facility representatives to ensure they verify radios are fully functional before acceptance.
Closure Date:
5 Conduct a risk assessment and provide guidance for the placement of resilient high-frequency radio networks within facilities and any needed monitoring schedules.
Closure Date:
6 Ensure sites can obtain repairs for broken or inoperable resilient high-frequency radio network equipment.
Closure Date:
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| 22-01594-86 | Inadequate Coordination of Care for a Patient at the West Palm Beach VA Healthcare System in Florida | Hotline Healthcare Inspection | ||
1 The West Palm Beach VA Healthcare System Director ensures that pulmonary providers communicate and document test results and surveillance care plans to patients.
Closure Date:
2 The West Palm Beach VA Healthcare System Director ensures that pulmonary providers and staff are trained on the use of return-to-clinic orders and monitors for compliance.
Closure Date:
3 The West Palm Beach VA Healthcare System Director ensures that chiropractor providers review community care notes and takes action as needed.
Closure Date:
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| 21-03680-80 | Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, IN | Hotline Healthcare Inspection | ||
1 The Richard L. Roudebush VA Medical Center Director conducts a comprehensive review of the patient’s care received in the Emergency Department and primary care setting, consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted, and takes action.
Closure Date:
2 The Richard L. Roudebush VA Medical Center Director evaluates the Emergency Department alcohol withdrawal treatment protocol and ensures policy aligns with evidence-based care guidelines.
Closure Date:
3 The Richard L. Roudebush VA Medical Center Director considers establishing written procedures for discharge planning in the Emergency Department, including documentation of contact with family members regarding notification of discharge and follow-up when applicable.
Closure Date:
4 The Richard L. Roudebush VA Medical Center Director expedites written guidance for primary care staff’s care coordination of patients discharged from the Emergency Department including documentation expectations and oversight responsibilities, and monitors compliance.
Closure Date:
5 The Richard L. Roudebush VA Medical Center Director conducts a full review of the patient’s care, determines if an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
6 The Richard L Roudebush VA Medical Center Director establishes a protocol for the administrative staff management of potentially urgent patient care needs, ensures training, and monitors compliance.
Closure Date:
7 The Richard L. Roudebush VA Medical Center Director develops procedures for the management of intoxicated patients in the primary care setting to include documentation of safe transport considerations.
Closure Date:
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| 21-01997-69 | Improvements Needed in Integrated Financial and Acquisition Management System Deployment to Help Ensure Program Objectives Can Be Met | Audit | ||
1 Implement controls to mitigate the risk that data are unreliable and inconsistently recorded between eCMS and iFAMS when staff deobligate funds for converted contracts.
Closure Date:
2 Establish and implement a methodology to prioritize user feedback into the risk management process.
Closure Date:
3 Use the risk register to document and assess the risks associated with the manual deobligation process.
Closure Date:
4 Ensure that converted contracts are included in integrated system testing and user acceptance testing.
Closure Date:
5 Implement a process that provides formal acknowledgment on whether requests related to high-priority business intelligence reports have been accepted as requirements.
Closure Date:
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| 22-01503-65 | Veterans Are Still Being Required to Attend Unwarranted Medical Reexaminations for Disability Benefits | Review | ||
1 Take action to help reduce unwarranted reexaminations by updating guidance and enhancing information systems to require rating specialists to cite objective evidence and provide justification for establishing reexamination controls.
Closure Date:
2 Consider establishing criteria to define a “locally-designated claims processor with expertise in review examination ordering” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations.
Closure Date:
3 Update training materials to include the guidance from VBA Policy Letter 21-01, “Updated Guidance on Routine Future Examination Requests” and ensure these claims processors meet all training requirements related to establishing and ordering medical reexaminations
Closure Date:
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| 22-00036-68 | Comprehensive Healthcare Inspection of the Amarillo VA Health Care System in Texas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance using objective criteria accepted by the practitioner.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews and evaluates licensed independent practitioners’ privileging requests and documents its review in the meeting minutes.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete Focused Professional Practice Evaluations and document results in practitioners’ profiles.
Closure Date:
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| 22-02721-77 | Stronger Controls Help Ensure People Barred from Paid Federal Healthcare Jobs Do Not Work for VHA | Administrative Investigation | ||
1 The chief for the Veterans Health Administration Office of Human Capital Management completes planned revisions of human resources policies and procedures to ensure that excluded individuals are not employed in paid positions using VA healthcare program funds, including requiring screening of candidates’ alternative or prior names or social security numbers (if accessible) against the List of Excluded Individuals and Entities prior to hiring.
Closure Date:
2 The executive director for the Veterans Health Administration Office of Integrity and Compliance implements planned revisions of policies and procedures for the Office of Integrity and Compliance to ensure it performs accurate List of Excluded Individuals and Entities monitoring, including for individuals with alternative or prior names or using social security numbers (if accessible), and provides timely notification of potential violations to appropriate staff.
Closure Date:
3 The executive director for the Veterans Health Administration (VHA) Office of Integrity and Compliance performs a one-time audit of VA employment records using corrected matching practices to determine whether any individuals on the List of Excluded Individuals and Entities are receiving payments using VA healthcare program funds, and, if so, whether additional revisions to policies and procedures of the VHA Office of Integrity and Compliance, the VHA Office of Human Capital Management, or any other element of VA are required to address the causes, including any related screening and/or monitoring process failures.
Closure Date:
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15770