Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-07053-51 | Biologic Implant Purchasing, Inventory Management, and Tracking Need Improvement | Audit | ||
1 Provide clarifying guidance and controls to clinic staff on making determinations to send purchase requests and consult notifications to the appropriate purchasing agents.
Closure Date:
2 Provide clarifying guidance to purchasing agents on how to effectively evaluate biologic implant purchase requests for the correct funding source.
Closure Date:
3 Provide clarifying guidance to prosthetic agents to ensure they receive clinic staff consult notifications on all prosthetic purchases of biologic implants.
Closure Date:
4 Create a biologic implant cost code for general-purpose funds to improve funding accountability and potentially assist in ensuring all biologic implant use is tracked.
Closure Date:
5 Direct the Procurement and Logistics Office to clarify guidance on the use of an approved inventory management system specific to biologic implants and the related VHA network, office, and facility staff responsibilities.
Closure Date:
6 Monitor facility compliance with the use of an approved inventory management system for completeness and accuracy.
7 Direct the Procurement and Logistics Office to ensure logistics staff perform inventory reviews of biologic implants, as required.
Closure Date:
8 Monitor medical facility compliance with required reviews of on-site inventory.
Closure Date:
9 Establish a structure for oversight responsibility that can provide guidance for tracking implanted biologics.
Closure Date:
10 Create policies and procedures for facilities to follow as they implement effective controls for tracking biologic implants.
Closure Date:
11 Establish standardized systems and requirements for facility staff to appropriately record necessary biologic implant attributes for accurate and accessible tracking of recipients to advance patient safety.
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| 20-02959-62 | Reporting and Monitoring Personal Protective Equipment Inventory during the Pandemic | Review | ||
1 Provide specific guidance for personnel in facilities and Veterans Integrated Service Network offices to report expired personal protective equipment supplies into the Response Monitoring Tool and refine the tool to allow the entry of expired supply levels on hand.
Closure Date:
2 Communicate effective verification measures for facilities and Veterans Integrated Service Networks to improve the reliability and consistency of reported personal protective equipment on-hand quantity and usage information.
Closure Date:
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| 20-00295-61 | VA Needs Better Internal Communication and Data Sharing to Strengthen the Administration of Spina Bifida Benefits | Review | ||
1 The OIG recommended that the under secretary for benefits and the under secretary for health formalize interagency sharing processes between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care on how data and information will be shared between both offices to prevent payments from continuing to deceased spina bifida beneficiaries.
Closure Date:
2 The OIG recommended that the under secretary for benefits and the under secretary for health take the following actions establish clear written guidance on sharing beneficiary data between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care to ensure all entitled beneficiaries are enrolled in health care.
Closure Date:
3 The OIG recommended that the under secretary for benefits institute standardized procedures to help the Veterans Benefits Administration’s national call center agents provide accurate and comprehensive information about spina bifida benefits.
Closure Date:
4 The OIG recommended that the under secretary for health direct the Veterans Health Administration’s Office of Community Care to develop a process to ensure those beneficiaries who are not using the services for which they are eligible, or need assistance with locating those services, receive them.
Closure Date:
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| 19-09129-76 | VHA’s Response following Cardiac Catheterization Lab Closure at the Samuel S. Stratton VA Medical Center in Albany, New York | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health should publish written guidance that clarifies roles and responsibilities of the national Cardiology program office, Veterans Integrated Service Networks, and Chief Medical Officers to review and opine on interventional cardiologist applicant’s qualifications for employment in those cases when facilities lack local interventional cardiology expertise and the facility’s Chief of Staff seeks subject matter expert opinion.
Closure Date:
2 The Veterans Integrated Service Network Director reviews circumstances that led to the failure
to respond to an OIG request for additional information and alters the person-dependent process
accordingly to ensure future OIG referrals are responded to timely and completely.
Closure Date:
3 The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.
Closure Date:
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| 18-00972-38 | Insufficient Oversight for Issuing Prosthetic Supplies and Devices | Audit | ||
1 Ensure Prosthetic and Sensory Aids Service business practice guidelines include specific requirements for conducting and properly documenting reviews of cloned and pending consults.
Closure Date:
2 Ensure Prosthetic and Sensory Aids Service staff develop a process to verify that consults include accessory and consumable supplies for prosthetic items prior to issuance.
Closure Date:
3 Ensure Prosthetic and Sensory Aids Service establishes field consistency requirements for conducting program reviews and evaluations.
Closure Date:
4 Ensure the executive director of the Prosthetic and Sensory Aids Service complies with existing policy for reviewing program assessments and evaluations and communicates review and evaluation results to the regional prosthetic representatives.
Closure Date:
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| 20-00339-69 | Communication of Test Results and Oncology Scheduling Concerns at the Beckley VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Beckley VA Medical Center Director ensures that primary care providers comply with communicating laboratory test results to patients and documenting the discussion in accordance with Veterans Health Administration policy.
Closure Date:
2 The Beckley VA Medical Center Director ensures that the oncologist complies with facility scheduling and ordering policies including the Primary Care and Oncology Service Agreement.
Closure Date:
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| 20-01036-70 | Misconduct by a Gynecological Provider at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates review of policies related to the role and training requirements of providers, including gynecologists, who conduct sensitive exams, to determine the need for the inclusion of trauma-informed care principles into training, policy, and practice.
Closure Date:
2 The Under Secretary for Health ensures a review of policies related to the role and training requirements of chaperones for sensitive examinations and takes action as appropriate.
3 The South Central VA Health Care Network Director evaluates processes for tracking patient complaints, takes appropriate action to ensure that facility staff enter all complaints into the Patient Advocate Tracking System, and ensures that the data are tracked, trended, and analyzed to identify significant issues and trends.
Closure Date:
4 The Gulf Coast Veterans Health Care System Director ensures staff education of the Veterans Health Administration and Gulf Coast Veterans Health Care System policies related to employee misconduct and monitors compliance.
Closure Date:
5 The Gulf Coast Veterans Health Care System Director reviews and evaluates policies related to administrative investigations, including fact-finding reviews and administrative investigation boards, to ensure such investigations are timely, objective, and documentation is sufficient to address the event under review.
Closure Date:
6 The Gulf Coast Veterans Health Care System Director and facility leaders review the subject gynecologist’s conduct and quality of care provided and meet all Veterans Health Administration requirements for state licensing board and National Practitioner Data Bank reporting.
Closure Date:
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| 20-01271-64 | Comprehensive Healthcare Inspection of the Dayton VA Medical Center in Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs include the minimum specialty-specific criteria for professional practice evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs complete and document focused professional practice evaluations on all newly hired licensed independent practitioners and evaluation results are reviewed and documented by the Clinical Executive Board.
Closure Date:
4 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
5 The Medical Center Director determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
6 The Medical Center Director determines the reasons for noncompliance and makes certain that the Multidisciplinary Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that qualified providers conduct four follow-up visits within 30 days of a High Risk for Suicide Patient Record Flag placement.
Closure Date:
8 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that clinicians complete patient safety plans within seven days before or after the current High Risk for Suicide Patient Record Flag date.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that life-sustaining treatment plans for patients who lack both decision-making capacity and a surrogate are referred to and reviewed by the assigned multidisciplinary committee.
Closure Date:
10 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
Closure Date:
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| 20-02779-59 | Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines | Hotline Healthcare Inspection | ||
1 The VA Manila Outpatient Clinic Manager evaluates the current pharmacy ordering processes and takes action to reduce the frequency of pharmacy stock shortages.
Closure Date:
2 The VA Manila Outpatient Clinic Manager reviews the impact of nonworking hours, including holidays, on pharmacy processing delays and takes action as necessary.
Closure Date:
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| 17-01980-201 | False Statements and Concealment of Material Information by VA Information Technology Staff | Administrative Investigation | ||
1 The Assistant Secretary for Information and Technology and Chief Information Officer confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the OIT program manager’s conduct.
Closure Date:
2 The Executive in Charge, Veterans Health Administration, confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the VHA employee’s conduct.
Closure Date:
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14957