Recommendations
2080
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-00247-210 | Comprehensive Healthcare Inspection of the VA Western Colorado Health Care System in Grand Junction | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board reviews aggregated quality, safety, and value data.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board’s recommended improvement actions are fully implemented and monitored.
Closure Date:
3 The Executive 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:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
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| 20-00418-166 | Ineffective Governance of Prescription Drug Return Program Creates Risk of Diversion and Limits Value to VA | Audit | ||
1 The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel secure prescription drugs set aside for return credit either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
Closure Date:
2 The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel account for all prescription drugs set aside for return credit when they leave the medical facility either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
Closure Date:
3 The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel maintain inventory management practices to make sure drugs that are returned for credit are returned in a timely manner, so that medical facilities do not miss opportunities to maximize the value of their drug returns or reduce their risk of overspending to replace drugs prematurely returned for credit.
Closure Date:
4 The OIG recommends that the under secretary for health takes steps to provide all offices and positions with defined national, network, or facility responsibilities for the drug return program or the administration of any future drug return contract(s), to include Pharmacy Benefits Management Services, Veterans Integrated Service Network pharmacist executives, network contracting officers, contracting officer representatives, and medical facility pharmacy chiefs, with the support, such as training, and the authority needed to carry out those responsibilities.
Closure Date:
5 The OIG recommends that the under secretary for health makes sure that Pharmacy Benefits Management Services reviews the drug return contractor(s) data for accuracy, and uses this data to identify unusual reimbursement patterns and potential improvements for revenue recovery through the last invoices issued as part of the October 2018 Pharma Logistics contract, and for any future drug return contract(s); and coordinate with the National Contract Service on corrective action if inaccurate contractor data is identified.
Closure Date:
6 The OIG recommends that the under secretary for health implements mechanisms to make sure that contracting officer representatives, if assigned, or Veterans Health Administration network contracting officers, provide oversight to ensure the contractor is performing in accordance with the terms of any future drug return contract(s).
Closure Date:
7 The OIG recommends that the under secretary for health, to minimize the risk of errors, makes sure that Veterans Health Administration network contracting officers when writing task orders off any future drug return contract(s) use a template with terms that align with any future drug return contract(s) developed by the National Contract Service.
Closure Date:
8 The OIG recommends that the under secretary for health coordinate with the VA Office of Acquisition, Logistics, and Construction’s principal executive director, who should develop a task order template with terms that align with any future drug return contract(s) and require the National Contract Service to disseminate the template to Veterans Health Administration network contracting officers.
Closure Date:
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| 20-01796-195 | Financial Efficiency Review of the Miami VA Healthcare System | Financial Inspection | ||
1 The OIG recommended the director of the Miami VA Healthcare System develop a plan to work with the assigned prime vendor to address having adequate stock from the facility’s formulary list in its warehouse to provide supplies when ordered.
Closure Date:
2 The OIG recommended the director of the Miami VA Healthcare System ensure logistics staff use the tools available to inform the Medical Supplies Program Office of prime vendor performance issues.
Closure Date:
3 The OIG recommended the director of the Miami VA Healthcare System establish controls to confirm approving officials and purchase cardholders review their proposed purchases and make sure contracting is used when it is in the best interest of the government.
Closure Date:
4 The OIG recommended the director of the Miami VA Healthcare System require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
Closure Date:
5 The OIG recommended the director of the Miami VA Healthcare System 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:
6 The OIG recommended the director of the Miami VA Healthcare System ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
Closure Date:
7 The OIG recommended the director of the Miami VA Healthcare System develop measures to confirm completed VA Form 0242 submissions are accurate and updated for all cardholders
Closure Date:
8 The OIG recommended the director of the Miami VA Healthcare System provide guidance on implementing the healthcare system policy “Resource Management Board,” including measurable objectives or clear criteria to determine if a service line is efficiently managing administrative staffing.
Closure Date:
9 The OIG recommended the director of the Miami VA Healthcare System establish controls to make certain that budget or accounting staff review the salary cost data each pay period and promptly address cost center corrections with human resources staff as needed.
Closure Date:
10 The OIG recommended the director of the Miami VA Healthcare System ensure service chiefs and supervisors review labor mapping for accuracy and completeness.
Closure Date:
11 The OIG recommended the director of the Miami VA Healthcare System continue to develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
Closure Date:
12 The OIG recommended the director of the Miami VA Healthcare System establish measures to improve compliance with the VA directive to avoid end of year pharmaceutical purchases.
Closure Date:
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| 21-00255-200 | Comprehensive Healthcare Inspection of the Sheridan VA Medical Center in Wyoming | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Peer Review Committee recommends improvement actions for Level 3 peer reviews.
Closure Date:
2 The Medical Center 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:
3 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
Closure Date:
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| 20-00041-163 | Improvements Still Needed in Processing Military Sexual Trauma Claims | Review | ||
1 Establish and implement a formal procedure to ensure all processing errors on claims identified by the review team are corrected and report the results to the OIG.
Closure Date:
2 Develop, implement, and monitor a written plan to address continuing military sexual trauma claims processing deficiencies identified by the review team, including reassessing previously decided claims when appropriate, and report the results to the OIG.
Closure Date:
3 Strengthen controls to effectively implement and promote compliance with 2018 OIG report recommendations related to military sexual trauma claims.
Closure Date:
4 Develop, implement, and monitor a written plan that requires the Compensation Service and the Office of Field Operations to strengthen communication, oversight, and accountability of military sexual trauma claims processing.
Closure Date:
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| 20-01979-199 | Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations | National Healthcare Review | ||
1 The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding protected administrative time, administrative staff support, and funding for outreach, education, and special project resources, with consideration of the Military Sexual Trauma Coordinators’ responsibilities, and takes action as warranted.
Closure Date:
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| 20-01262-191 | Comprehensive Healthcare Inspection of the Mann-Grandstaff VA Medical Center in Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director determines reasons for noncompliance and ensures that the Protected Peer Review Committee completes final reviews within 120 calendar days or has a written extension request approved by the Director.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses’ corresponding actions and outcome measures show sustained improvement.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in practitioners’ profiles.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic, with the veterans’ preference documented, within the required time frame.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete suicide safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five outreach activities each month.
Closure Date:
7 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual refresher training.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that written processes and procedures are in place for 24 hours per day, 7 days per week gynecological care.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned to and consistently attend Women Veterans Health Committee meetings.
Closure Date:
10 The Medical Center Director evaluates and determines the reasons for noncompliance and makes certain the Women Veterans Program Manager collects and tracks data for follow-up of abnormal mammogram and cervical cytology reports and the timeliness of breast and cervical cancer treatment.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
Closure Date:
12 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
13 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment complete competency assessments.
Closure Date:
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| 20-01254-185 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 20: VA Northwest Health Network in Vancouver, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines the reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead oversees facility development of corrective action plans within the required time frame and tracks action items until closure.
Closure Date:
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| 20-02828-174 | Opportunities Exist to Improve Management of Noninstitutional Care through the Veteran-Directed Care Program | Audit | ||
1 The OIG recommended the under secretary for health establish a process to ensure program personnel document veterans’ quarterly monitoring in their electronic health records, such as by using a standardized template.
Closure Date:
2 The OIG recommended the under secretary for health etablish a process to ensure the provider agency list in the Electronic Claims Adjudication Management System is updated as new provider agencies are added to the program.
Closure Date:
3 The OIG recommended the under secretary for health etablish a process to ensure proper pricing in the Electronic Claims Adjudication Management System when paying program claims.
Closure Date:
4 The OIG recommended the under secretary for health update program guidance on claims submission and processing to make sure provider agencies are aware of the need to include all required information when submitting program claims.
Closure Date:
5 The OIG recommended the under secretary for health establish guidance to include processes that medical facilities must follow to determine if veterans are receiving the same personal care services through the Veteran Directed Care program and the Program of Comprehensive Assistance for Family Caregivers, and how to address these situations, as appropriate.
Closure Date:
6 The OIG recommended the under secretary for health ensure program personnel determine if veterans enrolled in both the Veteran Directed Care and the Program of Comprehensive Assistance for Family Caregivers are receiving the same personal care services and take action, as appropriate.
Closure Date:
7 The OIG recommended the under secretary for health establish procedures to identify program staffing needs and define program personnel’s roles and responsibilities at the national, network, and local levels.
Closure Date:
8 The OIG recommended the under secretary for health update procedures for tracking and reporting demand for and use of program services and use these data to inform yearly cost estimates for the program.
Closure Date:
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| 20-02368-202 | Deficiencies in Mental Health Care Coordination and Administrative Processes for a Patient Who Died by Suicide, Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Hotline Healthcare Inspection | ||
1 The Ralph H. Johnson VA Medical Center Director ensures adherence to Veterans Health Administration policy in the renewal review of patients’ high risk for suicide patient record flag, and monitors compliance.
Closure Date:
2 The Ralph H. Johnson VA Medical Center Director evaluates compliance with Mental Health Treatment Coordinator assignment requirements, and takes action to address identified deficiencies as indicated.
Closure Date:
3 The Ralph H. Johnson VA Medical Center Director reviews the patient’s care to include staff’s adherence to “Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment” program requirements and appropriate outreach, consults with Human Resources and General Counsel Offices, and takes action as warranted.
Closure Date:
4 The Ralph H. Johnson VA Medical Center Director ensures that Mental Health Service staff complete patients’ suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.
Closure Date:
5 The Ralph H. Johnson VA Medical Center Director evaluates procedures for non-clinical staff to notify appropriate leaders of patient deaths by suicide, and takes action as needed.
Closure Date:
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15042