Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-00711-141 | Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Northern California Institute for Research and Education | Audit | ||
1 The San Francisco VA Healthcare System director establishes procedures to ensure the Research and Development Budget Office staff review VA-affiliated nonprofit corporation invoices to confirm services were performed or goods were received in accordance with Intergovernmental Personnel Act agreements before approving invoices for payment.
Closure Date:
2 The San Francisco VA Healthcare System director establishes procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of the VA-affiliated nonprofit corporation invoices authorized for payment by staff as required by VA Financial Policies and Procedures, Volume VIII, Chapter 1A.
Closure Date:
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| 19-06391-119 | Deficiencies in Nursing Care and Management in the Community Living Center at the Coatesville VA Medical Center, Pennsylvania | Hotline Healthcare Inspection | ||
1 The Coatesville VA Medical Center Director reviews and monitors staff compliance with the Community Living Center required nursing processes and documentation for medication administration, pain management assessments, and care plans.
Closure Date:
2 The Coatesville VA Medical Center Director examines Community Living Center nursing processes and ensures that required documentation for fall prevention assessments, which include measures such as bed positions, call bell access, and post-fall assessments, is completed and monitored.
Closure Date:
3 The Coatesville VA Medical Center Director reviews and monitors staff compliance with Community Living Center call bell processes and practices.
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4 The Coatesville VA Medical Center Director evaluates Community Living Center wound prevention processes and ensures that required wound documentation, including the measurement of patient weights and maintenance of skin integrity, is completed and monitored for compliance.
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5 The Coatesville VA Medical Center Director ensures that the newly developed Community Living Center hourly rounding form and process is approved in accordance with the facility’s standard operating procedure and aligns with the facility’s rounding policies, and monitors compliance.
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6 The Coatesville VA Medical Center Director makes sure that the fact-finding review process includes tracking and documenting issues through resolution and monitors compliance.
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7 The Coatesville VA Medical Center Director ensures that the Executive Leadership Board and the Geriatric and Extended Care Executive Council review, document, and track identified facility issues and, for the Executive Leadership Board, recommendations through resolution.
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8 The Coatesville VA Medical Center Director reviews and monitors the maintenance and functionality of essential safety equipment on Community Living Center units.
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9 The Coatesville VA Medical Center Director updates the facility staffing methodology policy and staffing methodology calculations to comply with current Veterans Health Administration staffing methodology requirements.
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| 19-08857-171 | Coordination of Care and Employee Satisfaction Concerns at the Community Living Center, Loch Raven VA Medical Center, in Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 The VA Maryland Health Care System Director conducts a comprehensive evaluation of the organizational health to include staff reporting of concerns and employee satisfaction at the Loch Raven Community Living Center, develops an action plan for improvement, and monitors progress.
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2 The VA Maryland Health Care System Director reviews current laboratory specimen handling procedures at the Loch Raven Community Living Center and implements an action plan to address identified deficiencies.
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3 The VA Maryland Health Care System Director ensures that concerns reported to Pathology &Laboratory Medicine Service are investigated and that action plans are instituted as needed.
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4 The VA Maryland Health Care System Director ensures Pathology & Laboratory Medicine Service staff notifies providers of critical laboratory results, documents in accordance with policy, and monitors compliance.
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5 The VA Maryland Health Care System Director reviews the current process for medication delivery, to include the effectiveness of recently initiated actions as described in the report, from the Baltimore VA Medical Center pharmacy to the Loch Raven Community Living Center and implements an action plan to address identified vulnerabilities.
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| 19-06249-94 | Disability Compensation Benefit Adjustments for Hospitalization Need Improvement | Audit | ||
1 The OIG recommended the under secretary for benefits correct disability compensation benefits for the veterans identified in the sample whose benefits were not adjusted or were incorrectly adjusted.
Closure Date:
2 The OIG recommended the under secretary for benefits develop and implement a plan to ensure all VA regional offices generate and process the weekly Admission Report for Service Connected Veterans and maintain coordinators’ logs to complete required benefit adjustments.
Closure Date:
3 The OIG recommended the under secretary for benefits continue to develop and implement a plan to nationally generate and process the Admission Report for Service Connected Veterans.
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4 The OIG recommended the under secretary for benefits determine if a statutory or regulatory change is required to ensure lawful, consistent, and timely processing of benefits for veterans entitled to temporary increases of benefits to 100 percent.
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5 The OIG recommended the under secretary for benefits develop and implement a plan to ensure staff receive refresher training when needed to properly process temporary disability compensation benefit adjustments for veterans hospitalized for more than 21 days that includes monitoring the effectiveness of the training.
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6 The OIG recommended the under secretary for benefits develop a plan to determine which veterans required adjustment of compensation benefits for hospitalization for a service connected condition, using the Admission Report for Service Connected Veterans for fiscal years 2018 and 2019, and make the required adjustments.
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| 18-04800-122 | VA’s Implementation of the FITARA Chief Information Officer Authority Enhancements | Audit | ||
1 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices develop and implement policy to support the Federal Information Technology Acquisition Reform Act delegation process and submit a Chief Information Officer Assignment Plan for the Office of Management and Budget’s review and approval.
Closure Date:
2 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices establish internal controls sufficient to ensure the Chief Information Officer or the appropriate delegate reviews and approves all information technology acquisitions, regardless of appropriation, and implement improved VA policies and procedures to reflect these business processes.
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3 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices modify all VA policy and guidance regarding implementation of Federal Information Technology Acquisition Reform Act requirements to provide clear and consistent Information Technology acquisition processes across the department.
Closure Date:
4 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administrations and program offices develop and implement agency wide information technology acquisition awareness and training programs to improve VA employees’ understanding of Federal Information Technology Acquisition Reform Act requirements and the Chief Information Officer’s authority to review and approval all information technology acquisitions.
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5 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices revise VA Directive 6008 to clarify the Chief Information Officer’s authority and roles in the planning, programming, budgeting, and execution of all information technology resources.
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6 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices develop and implement policies and procedures across all VA administration and staff offices to specifically identify and separate information resources from non-IT resources, regardless of funding appropriation.
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7 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices establish policies and procedures for all VA administration and staff offices to work with the Chief Information Officer for planning, programming, budgeting, and execution of all information technology resources and to manage VA’s overall information technology portfolio with resources that effectively achieve program and business objectives.
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8 The OIG recommends the Chief of Staff for Veterans Affairs ensures the Chief Information Officer, in conjunction with VA administration and staff offices establish and implement department-level information technology governance and oversight processes to ensure that the Chief Information Officer is a member of VA governance boards that inform decisions on all information technology resources across the agency, regardless of funding appropriation.
Closure Date:
9 The OIG recommends the VA Assistant Secretary for Information and Technology fully develop and implement the Office of Information and Technology governance framework to ensure Federal Information Technology Acquisition Reform Act requirements are met.
Closure Date:
10 The OIG recommends the VA Assistant Secretary for Information and Technology fully implement the functionality of the Office of Strategic Planning and Analysis to ensure Federal Information Technology Acquisition Reform Act compliance for information technology strategic planning.
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| 19-07482-91 | Improvements Needed to Reduce Aging Infrastructure Risks at Northport VA Medical Center in New York | Review | ||
1 Develop an oversight process that Northport VA Medical Center leaders can rely on to effectively develop, implement, and execute the master plan to reduce the footprint of the medical center and better manage the needs of its aging infrastructure.
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2 Ensure the Northport VA Medical Center director defines a timeline for executing the master plan and communicates the objectives to stakeholders to (1) instill consistency between the master and the strategic capital investment plans and (2) execute the master plan in accordance with agreed upon milestones and available resources.
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3 Make certain the Northport VA Medical Center director develops processes and procedures for submitting work orders, including making notifications when work orders are assigned and reviewing work orders for accuracy and consistency, to ensure the medical center’s engineering service is in the best position to prioritize work and manage its resources.
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| 20-00541-149 | VA Improved the Transparency of Mandatory Staffing and Vacancy Data | Review | ||
1 The assistant secretary for human resources and administration/ operations, security, and preparedness should ensure VA time to hire percentages are reported using the Office of Personnel Management’s target as required by Section 505(a)(1)(D) of the MISSION Act.
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2 The assistant secretary for human resources and administration/ operations, security, and preparedness should confer with the VA Office of General Counsel to ensure that changes to the reporting methodology comply with Section 505 of the MISSION Act.
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| 19-07091-159 | Death of a Patient, Deficiencies in Domiciliary Safety and Security, and Inadequate Contractual Agreement at the VA Northeast Ohio Healthcare System in Cleveland | Hotline Healthcare Inspection | ||
1 The VA Northeast Ohio Healthcare System Director conducts a full review of the patient’s care, including electrocardiograms and methadone initiation, and considers whether an institutional disclosure is warranted.
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2 The VA Northeast Ohio Healthcare System Director ensures that electrocardiograms are completed prior to and during methadone treatment in accordance with Veterans Health Administration Pharmacy Benefits Management Services recommendations.
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3 The VA Northeast Ohio Healthcare System Director ensures that domiciliary leaders implement a process to monitor the integrity of Volunteers of America staff documentation including health and safety rounding sheets and additional documentation directly pertaining to patients’ health, safety, and security.
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4 The VA Office of Asset Enterprise Management Director ensures that the Residential Services Agreement includes references to the Services Provider Contract between CGA LSVA Residential, LLC and Volunteers of America.
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5 The VA Office of Asset Enterprise Management Director, in consultation with the VA Office of General Counsel, determines if the Residential Services Agreement and the new term agreement needs to be reformed, or whether new contracts should be executed that clearly define the rights and responsibilities of all parties with respect to domiciliary services.
Closure Date:
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| 19-08256-124 | Delays in Diagnosis and Treatment and Concerns of Medical Management and Transfer of Patients at the Fayetteville VA Medical Center, North Carolina | Hotline Healthcare Inspection | ||
1 The Fayetteville VA Medical Center Director ensures that ordering providers review, acknowledge, and document an action plan for abnormal laboratory results.
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2 The Fayetteville VA Medical Center Director considers initiating an institutional disclosure for the failure of primary care provider 1’s clinical action and follow-up for Patient A’s abnormal test results and takes necessary actions.
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3 The Fayetteville VA Medical Center Director ensures that facility Community Care staff process Community Care consults according to the Veterans Health Administration policy.
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4 The Fayetteville VA Medical Center Director conducts a comprehensive review of Patient A’s and Patient B’s episode of care and takes action as indicated.
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5 The Fayetteville VA Medical Center Director evaluates the facility’s treating capabilities, delineates the medical conditions appropriate for admission, and updates the Policy for Admission/Discharge/Care of Patients to Intensive Care Unit.
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6 The Fayetteville VA Medical Center Director conducts an analysis of the inter-facility transfer process for patients in emergency situations, and develops and implements strategies and actions for improvement.
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7 The Fayetteville VA Medical Center Director updates the Patient Transfer Coordination policy to include the improvements from the transfer process analysis.
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8 The Fayetteville VA Medical Center Director makes certain that facility staff are trained on the updated Patient Transfer Coordination policy and emergency inter-facility transfer process for inpatients and monitors the process, including timeliness of transfers.
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9 The Fayetteville VA Medical Center Director reviews Patient B’s emergency medical services’ 911 call cancellation, considers initiating institutional disclosure, and takes appropriate action as indicated.
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10 The Fayetteville VA Medical Center Director ensures the Critical Care Committee thoroughly evaluates code blue events, identifies related performance and system issues, makes recommendations, and ensures actions are implemented.
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11 The Fayetteville VA Medical Center Director makes certain that solo practitioners have the privilege-specific competency components of their focused and ongoing professional practice evaluations performed by another provider with similar training and privileges and monitors compliance.
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12 The Fayetteville VA Medical Center Director ensures inter-facility patient data is collected, analyzed and incorporated into the facility’s quality management program.
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| 19-09563-142 | VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2019 | Review | ||
1 The Executive in Charge, Veterans Health Administration, implement appropriate IPERA testing procedures to ensure evidence is sufficient to verify that services were received for the Purchased Long-Term Services and Supports program.
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15039