Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00652-79 | Alleged Irregularities Regarding Physician Incentive Compensation Were Not Substantiated | Administrative Investigation | ||
1 The Medical Center Director audits the Dental Service Chief’s relative value unit productivity metric for fiscal years 2018 and 2019 and determines whether any erroneous payments for performance were made and issues bills of collection if deemed appropriate.
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| 20-02717-85 | Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health evaluates veteran access to VA Video Connect, including availability of equipment and reliable internet connectivity necessary to use VA Video Connect, and takes appropriate action.
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2 The Under Secretary for Health reviews the provision of veteran VA Video Connect training and support, and takes appropriate action.
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| 20-00427-92 | View Alert Process Failures and the Impact on Patient Care at the Central Alabama Veterans Health Care System in Montgomery | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health maintains consistent acting or interim leaders and expedites hiring of permanent leaders at the Central Alabama Veterans Health Care System.
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2 The VA Southeast Network Director ensures continued collaboration with the Central Alabama Veterans Health Care System to facilitate compliance with guidelines related to view alert management and monitors for ongoing efficiency and sustainability.
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3 The Central Alabama Veterans Health Care System Director will continue to evaluate and assess the Central Alabama Veterans Health Care System’s view alert management process, effectiveness of its action plan, and modify as indicated.
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4 The Central Alabama Veterans Health Care System Director ensures that initial and ongoing provider training and support for the clinical management of view alerts is provided, and monitors compliance.
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5 The Central Alabama Veterans Health Care System Director issues guidance and ensures providers are trained on a clearly defined process for the designation of surrogates and the associated responsibilities, and monitors compliance.
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6 The Central Alabama Veterans Health Care System Director evaluates the two cases discussed in this report to determine if an institutional disclosure or formal quality management review is needed and takes action accordingly.
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7 The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on the unmanaged abnormal laboratory test and imaging results to include those that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
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8 The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on unscheduled community care consults that were discontinued after 90 days that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
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9 The Central Alabama Veterans Health Care System Director ensures the development and implementation of a policy to address the communication of all test results to ordering providers, or designee, and to patients as required by Veterans Health Administration policy, and monitors compliance.
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10 The Central Alabama Veterans Health Care System Director ensures that audits of abnormal laboratory and imaging test results, and unscheduled community care consults that were discontinued after 90 days, are completed to verify providers have managed the associated view alerts, and monitors compliance.
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11 The Central Alabama Veterans Health Care System Director ensures that pending actions are completed for the 33 patient cases with clinical issues referred to the system by the Office of the Inspector General.
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| 20-01387-89 | Colonoscope Reprocessing at Multispecialty Community-Based Outpatient Clinics | National Healthcare Review | ||
1 The Under Secretary for Health requires facility directors ensure that staff who reprocess colonoscopes at community-based outpatient clinics complete initial training within the required 90 days prior to independently reprocessing equipment and maintain documentation.
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2 The Under Secretary for Health requires facility directors confirm that sterile processing services staff who reprocess colonoscopes at community-based outpatient clinics receive ongoing continuing education through monthly in-services and maintain documentation.
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| 20-00102-73 | Handling Administrative Errors at the Chicago VA Regional Benefits Office in Illinois | Review | ||
1 The director of the Chicago VA regional benefits office ensure the errors identified by the review team are corrected.
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2 The director of the Chicago VA regional benefits office monitor the effectiveness of the actions taken to improve the accuracy of administrative error corrections, and determine what additional measures, if any, are needed to make certain that claims processors understand how to apply national and local procedures for correcting administrative errors.
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| 19-06147-50 | Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Distribution Fee Invoicing | Audit | ||
1 Direct the Medical Supplies Program Office to implement procedures requiring chief logistics officers at Veterans Integrated Service Networks to monitor facility processes for verification and certification of distribution fee invoices to ensure invoice accuracy prior to payment by the Financial Services Center.
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2 Require Veterans Integrated Service Network directors to ensure their chief logistics officers develop distribution fee monitoring and review procedures for facility logistics audits and compliance reviews to ensure invoices are adequately reviewed, verified, and certified.
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3 Require Veterans Integrated Service Network directors to ensure facility chief logistics officers and contracting officer’s representatives review and update the election forms according to contract requirements and provide copies to the Medical/Surgical Prime Vendors for acknowledgment.
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4 Require Veterans Integrated Service Network directors to ensure facility contracting officer’s representatives verify that distribution fee rates match with those on the election forms and pricing schedule by comparing transaction data from the vendors to VHA-maintained transaction data, and reconcile payments as appropriate.
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5 Require the Strategic Acquisition Center to develop and add modifications to the Medical/ Surgical Prime Vendor-Next Generation contract requiring prime vendors to provide reports to VA medical facilities with detailed medical and surgical transaction data, fee amounts, and fee percentage rates applied to each transaction on distribution fee invoices.
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6 Require the Strategic Acquisition Center contracting officer to work with the Medical Supplies Program Office to ensure that Medical/Surgical Prime Vendor contracting officer’s representatives are assigned to each VA medical facility.
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7 Require the Strategic Acquisition Center to appropriately modify the Medical/Surgical Prime Vendor contract to define annual facility purchase as well as adding a provision for paying the annual facility purchase amount based on the estimated total spend until year-end reconciliation.
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8 Require the Strategic Acquisition Center to also appropriately modify the Medical/ Surgical Prime Vendor contract to require the prime vendors—rather than the facility—to reconcile to annual facility purchases at the end of the year.
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9 Require the Medical Supplies Program Office to establish policy that clearly defines the source VA medical facilities should use to estimate their annual facility purchase amounts and determine the year-end amounts.
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10 Require VA medical facilities to review their on-site representative fees paid during fiscal year 2018 and future years to ensure they were paid based on the actual annual facility purchase amounts, consistent with the Medical/Surgical Prime Vendor-Next Generation contract, and reconcile payment discrepancies as appropriate.
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| 20-00130-86 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 7: VA Southeast Network in Duluth, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the development of a written policy that establishes and maintains a comprehensive environment of care program at the Veterans Integrated Service Network level.
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2 The Network Director evaluates and determines any additional reasons for noncompliance and ensures an annual review of the Emergency and Continuity of Operations Plans; Hazards Vulnerability Analysis; and collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement are submitted to executive leaders for review and approval.
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3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to executive leaders.
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4 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain the lead Women Veterans Program Manager completes annual site visits at each facility.
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5 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager completes assessments to identify staff education gaps related to women’s health and develops or adapts educational programs, materials, and/or resources where gaps are identified.
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6 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network-led facility reusable medical equipment inspection results are posted within the required time frame.
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7 The Network Director evaluates and determines additional reasons for noncompliance and ensures that facility corrective action plans are developed within the required time frame.
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| 20-00421-63 | VBA Did Not Consistently Comply with Skills Certification Mandates for Compensation and Pension Claims Processors | Review | ||
1 The under secretary for benefits creates written guidelines for tracking, identifying, notifying, registering, and exempting individuals required to take skills certification tests.
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2 The under secretary for benefits establishes a tracking mechanism to ensure all eligible individuals required to take tests are identified and notified of testing dates at least 30 days prior to test administration.
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3 The under secretary for benefits provides an update to the plan submitted to Congress explaining why all employees and supervisors who have claims-processing functions listed in the original plan are not subject to skills certification testing.
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4 The under secretary for benefits implements a plan to ensure staff who failed their most recent skills certification test and remain in the same position are provided training from individual training plans to remediate the deficiencies in their skills and competencies.
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5 The under secretary for benefits establishes an oversight plan to ensure training set out in approved training plans is provided to individuals who fail skills certification tests.
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6 The under secretary for benefits notifies Congress of plans to take personnel actions against individuals who fail consecutive skills certification tests after remediation for the same positions in compliance with the Honoring America’s Veterans and Caring for Camp Lejeune Families Act of 2012.
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| 19-06902-23 | The Office of Community Care’s Oversight of Non-VA Healthcare Claims Processed by Its Contractor | Audit | ||
1 The OIG recommended the under secretary for health ensures the Payment Operations and Management directorate reevaluates all sample claims identified in this audit as not processed in accordance with Office of Community Care guidance, and takes appropriate corrective action as needed.
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2 The OIG recommended the under secretary for health ensures there is a contract requirement that the contractor’s employees must follow Office of Community Care guidance for processing non-VA care claims.
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3 The OIG recommended the under secretary for health ensures the contractor’s standard operating procedures for claims processing are accurate and a mechanism is put in place to keep the contractor’s procedures updated to reflect current Office of Community Care claims processing procedures.
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4 The OIG recommended the under secretary for health ensures the Office of Community Care develops and implements clear controls for reviewing and updating, if necessary, the quality assurance surveillance plan requirements at least annually
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5 The OIG recommended the under secretary for health ensures the Payment Operations and Management personnel make full use of the established communication tracking tool.
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6 The OIG recommended the under secretary for health ensures the Payment Operations and Management leaders provide timely training and additional guidance to their staff and the contractor’s employees on applying and using standardized denial and rejection reasons, and employees follow procedures to process claims with no authorizations to ensure consistent and accurate claims processing.
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| 20-00563-68 | Mammography Program Deficiencies and Patient Results Communication at the Washington DC VA Medical Center | Hotline Healthcare Inspection | ||
1 The Washington DC VA Medical Center Director evaluates documentation processes for entering the Breast Imaging-Reporting and Data System as primary diagnostic codes in the electronic health record and takes actions as necessary.
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2 The Washington DC VA Medical Center Director evaluates the processes for notification of mammography exam results by ordering providers and takes actions as necessary.
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3 The Washington DC VA Medical Center Director fully implements action plans for all issues listed in the September 2019 National Radiology Program Office site visit and monitors to completion.
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4 The National Radiology Program Office ensures mammography programs have a comprehensive standard operating procedure manual and confirms compliance.
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5 The Washington DC VA Medical Center Director develops and implements a comprehensive standard operating procedure manual covering critical technical, clerical, and administrative functions for the facility’s Mammography Program.
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6 The Washington DC VA Medical Center Director evaluates the oversight and training processes for the facility’s Mammography Program medical support assistant and takes actions as necessary.
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7 The Washington DC VA Medical Center Director evaluates mammography technology staff training processes and takes actions to ensure mammography technology staff receive training through a formalized program.
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14957