Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-03898-236 | Improper Processing of Automated Pension Reductions Based on Social Security Cost of Living Adjustments | Review | ||
1 The OIG recommended the under secretary for benefits update the Veterans Benefits Administration’s adjudication procedures manual section related to notices of proposed adverse action to ensure automated notices align with the Veterans Affairs regulation, which requires material facts and detailed reasons for the proposed decision.
Closure Date:
2 The OIG recommended the under secretary for benefits amend the language of the automated notices of proposed adverse action to include all material facts and detailed reasons for the proposed decision.
Closure Date:
3 The OIG recommended the under secretary for benefits review all automatically completed fiscal year 2020 pension reductions based on Social Security cost of living adjustments to ensure regulations and procedures were followed, including consideration of supplementary medical insurance premiums and all evidence submitted by the beneficiary.
Closure Date:
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| 21-00270-04 | Comprehensive Healthcare Inspection of the VA Caribbean Healthcare System in San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses have actions and associated outcome measures.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend the Surgical Workgroup meetings.
Closure Date:
4 The Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
5 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring physicians or the assigned designees send active medication lists to the receiving facilities during inter-facility transfers.
Closure Date:
6 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
7 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System.
Closure Date:
9 The Director evaluates and determines any additional reasons for noncompliance and ensures the required interdisciplinary team conducts a Workplace Behavioral Risk Assessment each fiscal year.
Closure Date:
10 The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
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| 19-06004-225 | Veterans Integrated Service Network 21’s Management of Medical Facilities’ Nonrecurring Maintenance | Audit | ||
1 The director of the VA Sierra Pacific Network (VISN 21) should ensure out-of-cycle projects conform to NRM policy urgent-need criteria before approving projects.
Closure Date:
2 The director of VISN 21 should study the feasibility of using non-engineering staff to oversee NRM contracts, contracting out for project requirements to free up VISN engineering resources, and sharing engineering resources between VISN 21 facilities.
Closure Date:
3 The under secretary for health should implement an engineering staffing model for medical facilities that supports the achievement of VA strategic goals.
Closure Date:
4 The under secretary for health should perform annual reviews of the engineering staffing model to determine if adjustments are needed to achieve VA strategic goals.
Closure Date:
5 The under secretary for health should ensure medical facilities design long-range action plans that are feasible based on expected NRM budget levels.
Closure Date:
6 The executive director of the Office of Asset Enterprise Management, in coordination with the under secretary for health, should enforce NRM policy’s urgent-need criteria on out-of-cycle NRM project approvals.
Closure Date:
7 The under secretary for health in coordination with the executive director of the Office of Asset Enterprise Management should create a standardized set of performance measures and reporting standards for offices involved in developing, approving, and executing long-range action plans to ensure NRM projects that align with strategic goals are executed.
Closure Date:
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| 21-00274-289 | Comprehensive Healthcare Inspection of the James A. Haley Veterans' Hospital in Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines additional reasons for noncompliance and ensures the Surgical Workgroup conducts a monthly review of surgical deaths.
Closure Date:
2 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members participate in disruptive behavior event reviews.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Closure Date:
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| 21-00267-290 | Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures disclosure of adverse events that require an institutional disclosure.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths monthly.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide prevention safety plans.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System include information regarding patients’ right to appeal the orders and the appeals process.
Closure Date:
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| 20-02014-270 | Vet Center Inspection of Southeast District 2 Zone 2 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons clinical and administrative quality reviews were not completed and monitors compliance.
Closure Date:
2 The District Director evaluates the clinical and administrative quality review report approval process to determine if a timeliness measure is needed and takes action as indicated.
Closure Date:
3 The District Director determines reasons clinical and administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.
Closure Date:
4 The District Director evaluates the process for resolution of clinical and administrative quality review deficiencies and takes action as necessary.
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5 The District Director determines reasons for noncompliance with critical incident quality review (currently known as morbidity and mortality review) of a death by suicide, ensures completion includes an evaluation of vet center services to determine if actions are needed to improve the effectiveness of vet center suicide prevention activities, and monitors compliance.
Closure Date:
6 The District Director determines reasons for noncompliance with critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts, ensures completion, and monitors compliance.
Closure Date:
7 The District Director ensures intake assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
8 The District Director ensures military histories are completed and monitors compliance across all zone vet centers.
Closure Date:
9 The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
10 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 unavailable in RCSnet and ensures compliance with standards for timely completion of intake assessments and military histories.
Closure Date:
11 The District Director determines reasons the Clearwater Vet Center did not have nontraditional hours as required and ensures compliance.
Closure Date:
12 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with the Clearwater, Ocala, Ponce, and Sarasota Vet Centers staff participation on mental health councils, and takes action as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
13 The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with vet centers’ receipt of the monthly Office of Mental Health and Suicide Prevention list of clients with an increased predictive risk for suicide, ensures coordination of care with VA medical facilities for vet center clients on the list, and monitors compliance.
Closure Date:
14 The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine the reasons updated lists of clients designated as high risk for suicide were not consistently received by vet centers, and ensures a process for vet centers’ receipt of the list in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding.
Closure Date:
15 The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with a standardized communication and collaboration process between suicide prevention coordinators and vet centers in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding, and initiates action as necessary.
Closure Date:
16 The District Director determines reasons for noncompliance with high risk for suicide flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Sarasota Vet Center, takes action to ensure requirement is met, and monitors compliance.
Closure Date:
17 The District Director determines reasons for noncompliance with processes for completing and tracking four hours of external clinical consultation per month at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures that vet center directors implement processes, and monitors compliance.
Closure Date:
18 The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
19 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
20 The District Director determines reasons for errors in training assignments and why completed trainings are not being recorded for employees at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures all staff complete mandatory trainings as required, and monitors compliance.
Closure Date:
21 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.
Closure Date:
22 The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Clearwater and Sarasota Vet Centers and ensures all vet center employees safely and securely store protected health information.
Closure Date:
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| 20-04051-287 | Vet Center Inspection of Continental District 4 Zone 2 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons administrative quality reviews were not completed, ensures completion, and monitors compliance.
Closure Date:
2 The District Director evaluates the administrative quality review report approval process to determine if a timeliness measure is needed and takes actions as indicated.
Closure Date:
3 The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.
Closure Date:
4 The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.
Closure Date:
5 The District Director determines reasons for non-participation with the root cause analysis investigation for shared clients with the support Veterans Affairs medical facility and establishes processes to ensure required vet center participation.
Closure Date:
6 The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
Closure Date:
7 The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
8 The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
Closure Date:
9 The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
10 The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff consult with the vet center director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
Closure Date:
13 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on mental health councils at Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
14 The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures vet center directors implement processes, and monitors compliance.
Closure Date:
15 The District Director determines reasons for noncompliance with staff supervision provided by the vet center directors at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
16 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
17 The District Director determines reasons why completed trainings are not being recorded for employees at the Alexandria, Laredo, and Mesquite Vet Centers, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
18 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Alexandria, Houston Southwest, Laredo, and Mesquite Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
Closure Date:
19 The District Director reviews reasons for noncompliance related to the Mesquite Vet Center’s emergency and crisis plan not containing all required components and ensures compliance.
Closure Date:
20 The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Houston Southwest Vet Center and ensures all vet center employees safely and securely store personally identifiable information.
Closure Date:
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| 21-01805-286 | Vet Center Inspection of Pacific District 5 Zone 1 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons clinical quality review remediation plans were not completed, ensures completion, and monitors compliance.
Closure Date:
2 The District Director determines reasons administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.
Closure Date:
3 The District Director evaluates the process for resolution of administrative quality review deficiencies and initiates action as necessary.
Closure Date:
4 The District Director determines reasons why critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts were not completed, ensures completion, and monitors compliance.
Closure Date:
5 The District Director ensures the intake portion of the psychosocial assessment is 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 why completion dates are not available in RCSnet and ensures compliance with standards for timely completion of intake assessments, military histories, and lethality risk assessments.
Closure Date:
8 The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
9 The District Director verifies 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 confirms clinical staff make timely notification to the suicide prevention coordinator at the support Veterans Affairs medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff consult with the Vet Center Director, external clinical consultant, or VA suicide prevention coordinator following a client’s lethality status change as required, and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director ensures clinical staff complete crisis reports as required and monitors compliance across all zone vet centers.
Closure Date:
13 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Central Oregon Vet Center and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
14 The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Bellingham Vet Center, takes action to ensure requirements are met, and monitors compliance.
Closure Date:
15 The District Director determines reasons the Bellingham Vet Center did not have a written crisis plan, ensures requirements related to crisis plans are met and monitors compliance.
Closure Date:
16 The District Director determines reasons for noncompliance with the appointment of a clinical liaison at the Tacoma Vet Center, ensures assignment of a liaison, and monitors compliance.
Closure Date:
17 The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures Vet Center Directors implement processes, and monitors compliance.
Closure Date:
18 The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
19 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
20 The District Director determines reasons employees at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
21 The District Director evaluates and determines reasons for noncompliance with a presentable exterior at the Wasilla Vet Center and ensures all exterior grounds are in good repair.
Closure Date:
22 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Bellingham, Central Oregon, Tacoma, and Wasilla Vet Centers and ensures all exit doors are compliant with Architectural Barriers Act requirements.
Closure Date:
23 The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Bellingham and Tacoma Vet Centers and ensures all vet center employees safely and securely store protected health information.
Closure Date:
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| 21-00268-273 | Comprehensive Healthcare Inspection of the Miami VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
2 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and ensure that staff use the VA Inter-Facility Transfer Form or an equivalent note to document inter-facility transfers.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that referring physicians record all required elements in the electronic health record prior to patient transfers.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
5 The System 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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| 21-00266-281 | Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System in West Haven | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Performance Improvement Committee meetings.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
3 The System Director evaluates and determines additional reasons for noncompliance and maintains a current written policy to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
4 The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
5 The System Director and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that referring physicians identify the receiving physicians on the Inter-Facility Transfer Form or facility-defined equivalent note.
Closure Date:
6 The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure nurse-to-nurse communication occurs during the inter-facility transfer process.
Closure Date:
7 The Chief of Staff and Associate Director for Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
8 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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14957