Recommendations
2080
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-00345-77 | Inadequate Oversight of Contractors’ Personal Identity Verification Cards Puts Veterans’ Sensitive Information and Facility Security at Risk | Review | ||
1 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers obtain and maintain evidence of contractor-provided lists of all personal identity verification cards issued to contractor employees.
2 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers maintain evidence documenting personal identity verification cards were returned to the issuing or designated office when the cards were no longer required and prior to closing the contract.
3 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to evaluate the role of contracting officer’s representatives in the personal identity verification card process for contractor employees and assess whether updates to their letter of delegation and standard operating procedures are necessary.
4 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish policies and procedures outlining specific supervisory responsibilities for contracting officer oversight in accordance with the Government Accountability Office Standards for Internal Controls in the Federal Government.
Closure Date:
5 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess the contract completion statement template to determine whether to include the contractor-related personal identity verification card requirements.
Closure Date:
6 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures within the Procurement Audit Office for periodic reviews of contract files to determine compliance with the personal identity verification card requirements established in the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, require the results of these reviews to be reported to senior management to help determine whether corrective actions are required.
7 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to determine whether existing or planned systems can have the functionality to allow management to effectively and routinely monitor contractor employee personal identity verification cards or whether a new system should be established.
Closure Date:
8 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess whether contracting officers should be required to include the contractor-provided list as an explicit requirement in all Veterans Health Administration contracts that require issuance of personal identity verification cards to contractor employees.
9 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures to ensure contracting officers include Federal Acquisition Regulation clause 52.204-9, “Personal Identity Verification of Contractor Personnel,” in contracts when required.
Closure Date:
10 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to consider directing contracting officers to delay final payment to contractors on future contracts until all personal identity verification cards have been returned.
Closure Date:
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| 19-09808-171 | Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
Closure Date:
2 The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
Closure Date:
3 The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
Closure Date:
4 The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
Closure Date:
5 The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
Closure Date:
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| 20-00176-125 | Veterans Cemetery Grants Program Did Not Always Award Grants to Cemeteries Correctly and Hold States to Standards | Audit | ||
1 The OIG recommended the under secretary for memorial affairs develop controls to ensure state grants are prioritized and awarded in accordance with the Code of Federal Regulations.
Closure Date:
2 The OIG recommended the under secretary for memorial affairs develop and implement written policies and procedures for grant prioritization.
Closure Date:
3 The OIG recommended the under secretary for memorial affairs evaluate all current national headstone and niche cover contracts for appropriate penalties and clauses for timeliness and quality issues and enforce and amend those contracts as necessary.
Closure Date:
4 The OIG recommended the under secretary for memorial affairs direct the Improvement and Compliance Service to assign levels of importance to standards and measures used for compliance reviews and test the inscription accuracy of all gravesites sampled.
Closure Date:
5 The OIG recommended the under secretary for memorial affairs require all state and tribal cemeteries to submit certified condition and operations performance assessments annually.
Closure Date:
6 The OIG recommended the under secretary for memorial affairs ensure representatives from all state and tribal cemeteries are provided opportunities to participate in National Cemetery Administration standards training via remote training options and monitor all training to ensure adequate participation.
Closure Date:
7 The OIG recommended the under secretary for memorial affairs continue to seek an increase in cemetery grant funding in excess of $45 million
Closure Date:
8 The OIG recommended the under secretary for memorial affairs ensure that the Improvement and Compliance Service follows up with Hawaiian cemeteries after action plans are submitted to ensure deficiencies are corrected.
Closure Date:
9 The OIG recommended the under secretary for memorial affairs implement controls to ensure cemeteries that receive provisionally compliant or noncompliant scores during reviews are followed up with on a fixed and regular basis until sufficient corrective action plans are submitted.
Closure Date:
10 The OIG recommended the under secretary for memorial affairs use accountability measures in the Code of Federal Regulations when appropriate if grantees do not take adequate steps to correct significant long standing deficiencies.
Closure Date:
11 The OIG recommended the under secretary for memorial affairs work with the State of Hawaii Office of Veterans’ Services to conduct an extensive assessment of all eight Hawaii state veterans cemeteries, including organizational oversight and operations, staffing needs (including training), gravesite marker accuracy, and grounds conditions.
Closure Date:
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| 20-01273-162 | Comprehensive Healthcare Inspection of the John D. Dingell VA Medical Center in Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a first- or second-line supervisor completes a provider exit review form within seven business days of a licensed independent practitioner’s departure from the medical center.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all employees complete suicide prevention refresher training.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned to the Women Veterans Health Committee.
Closure Date:
4 The Medical Center Director 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:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
Closure Date:
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| 20-01141-145 | VHA Needs More Reliable Data to Better Monitor the Timeliness of Emergency Care | Audit | ||
1 The OIG recommended the under secretary for health
ensure Baltimore VA Medical Center leaders reevaluate their corrective action plan and adjust as needed.
Closure Date:
2 The OIG recommended the under secretary for health make certain relevant staff receive appropriate training on recording wait times in the software.
Closure Date:
3 The OIG recommended the under secretary for health strengthen reliability reviews of Emergency Department Integration Software data to mitigate the risk of inaccurate records.
Closure Date:
4 The OIG recommended the under secretary for health establish routine oversight responsibilities for Veterans Integrated Service Network and facility leaders of emergency departments’ efforts to improve the reliability of their emergency department data.
Closure Date:
5 The OIG recommended the under secretary for health improve the monitoring of data for patients with the highest Emergency Severity Index levels of one or two receiving emergency care services.
Closure Date:
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| 20-02968-170 | Improper Feeding of a Community Living Center Patient Who Died and Inadequate Review of the Patient’s Care, VA New York Harbor Healthcare System in Queens | Hotline Healthcare Inspection | ||
1 The VA New York Harbor Healthcare System Director reviews the process of evaluating the Community Living Center nursing staff’s competency for resident feeding and validates their ability to safely feed residents.
Closure Date:
2 The VA New York Harbor Healthcare System Director ensures that Community Living Center nursing staff are trained on documentation requirements related to feeding of residents and verifies compliance with requirements.
Closure Date:
3 The VA New York Harbor Healthcare System Director evaluates documentation of resident feeding, including identifying the staff member who feeds a resident, and takes action as indicated.
Closure Date:
4 The VA New York Harbor Healthcare System Director verifies that a comprehensive review of the patient’s care and death is completed, and evaluates the usefulness of including the pictures and video of the chicken in the review, and takes action as indicated.
Closure Date:
5 The VA New York Harbor Healthcare System Director ensures the Cardiopulmonary Resuscitative Committee evaluates identified issues and makes recommendations for improvement, confirms actions are implemented, and assesses the effectiveness of actions.
Closure Date:
6 The VA New York Harbor Healthcare System Director verifies staff are aware of what constitutes an adverse event and the requirements to submit incident reports when witnessing or becoming aware of an adverse event.
Closure Date:
7 The VA New York Harbor Healthcare System Director evaluates the circumstances surrounding the patient’s death to determine if an institutional disclosure is warranted
Closure Date:
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| 20-01485-114 | Inspection of Information Technology Security at the VA Outpatient Clinic in Austin, Texas | Information Security Inspection | ||
1 The OIG recommended the area manager for the Central Texas Veterans Health Care System implement more effective automated inventory management tools.
Closure Date:
2 The OIG recommended the area manager for the Central Texas Veterans Health Care System implement a more effective patch and vulnerability management program that can accurately identify vulnerabilities and enforce patch application.
Closure Date:
3 The OIG recommended the area manager for the Central Texas Veterans Health Care System ensure compliance with the media protection standard operating procedure for all employees who work with media storage and ensure compliance with marking and sanitization provisions.
Closure Date:
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| 19-08658-153 | Improvements Needed in Adding Non-VA Medical Records to Veterans’ Electronic Health Records | Audit | ||
1 Ensure facilities create and implement standard operating procedures that clearly define all Health Information Management and community care staff responsibilities and the procedures for accurately scanning, importing, and indexing non-VA medical records.
Closure Date:
2 Require facility directors ensure that Health Information Management leaders provide or formally delegate training, quality checks, and quality assurance monitoring for community care staff responsible for medical record management.
Closure Date:
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| 19-07719-113 | Stronger Financial Management Practices Are Needed at VA's Maryland Health Care System | Review | ||
1 The OIG recommended the Maryland Health Care System director implement internal controls for healthcare system staff to submit and document approvals for all equipment requests in the Enterprise Equipment Request Portal before ordering and paying for equipment.
Closure Date:
2 The OIG recommended the Maryland Health Care System director implement a control requiring staff to justify the waiver of any healthcare system approvals ordinarily required to purchase equipment in the Enterprise Equipment Request Portal.
Closure Date:
3 The OIG recommended the Maryland Health Care System director inform the deputy under secretary for health for operations and management for procurement and logistics of the internal control weakness in the Enterprise Equipment Request Portal and request a response regarding whether corrective action is necessary.
Closure Date:
4 The OIG recommended the Maryland Health Care System director require the logistics service to develop a plan for working with the prime vendor to ensure historical and current estimated supply data are timely, accurate, and meet healthcare system supply requirements.
Closure Date:
5 The OIG recommended the Maryland Health Care System director ensure the logistics service implements a plan to monitor for and correct unit conversion factor errors consistently and promptly.
Closure Date:
6 The OIG recommended the Maryland Health Care System director establish processes and controls for cardholders to comply with the record retention requirements in the Federal Acquisition Regulation and VA’s Financial Policy, Volume XVI, “Charge Card Program.”
Closure Date:
7 The OIG recommended the Maryland Health Care System director ensure all staff are provided clear guidance on overtime approval and payment policies and procedures that meet VA requirements.
Closure Date:
8 The OIG recommended the Maryland Health Care System director implement policies and procedures for supervisors to effectively monitor overtime worked and maintain documentation required to support related payments.
Closure Date:
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| 20-01270-154 | Comprehensive Healthcare Inspection of the VA Northern Indiana Health Care System in Marion | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs base reprivileging decisions on service-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs ensure that ongoing professional practice evaluations for radiation oncologists include the minimum radiation oncology-specific criteria.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ determinations to continue privileges are based, in part, on results of ongoing professional practice evaluation activities.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Clinical Executive Board’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed independent practitioners’ departure from the healthcare system.
Closure Date:
7 The System Director evaluates and determines any additional reasons for noncompliance and ensures state licensing board reporting is initiated when a provider fails to meet generally accepted standards of practice.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse, mental health problems or disorders, and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
Closure Date:
12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention safety plans are completed within the required time frame.
Closure Date:
13 The System Director evaluates and determines any additional reasons for noncompliance and ensures employees complete annual suicide prevention refresher training.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that gynecological care coverage is available 24 hours a day, 7 days per week.
Closure Date:
15 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief performs an annual risk analysis and reports the results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
17 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures the Sterile Processing Services supervisor enforces the daily cleaning schedule at the Fort Wayne campus.
Closure Date:
18 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
19 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees who reprocess reusable medical equipment complete competency assessments.
Closure Date:
20 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services employees receive monthly continuing education.
Closure Date:
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15042