Recommendations
2099
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00524-104 | Better Communication and Oversight Could Improve How the Pain Management, Opioid Safety, and Prescription Drug Monitoring Program Manages Funds | Audit | ||
1 Instruct the program to communicate pertinent annual funding guidance related to Pain Management, Opioid Safety, and Prescription Drug Monitoring Program initiatives before the start of the upcoming fiscal years so that Veterans Integrated Service Networks and medical facilities can adequately plan and take appropriate hiring actions needed to spend their funds.
Closure Date:
2 Ensure the program communicates pertinent funding information related to Pain Management, Opioid Safety, and Prescription Drug Monitoring Program initiatives with key personnel—such as program coordinators and Veterans Integrated Service Network and medical facility leaders.
Closure Date:
3 Ensure the program clarifies and defines requirements for pain management teams in the new Veterans Health Administration Directive 1151, Pain Management and Opioid Safety.
4 Establish means to periodically validate the status information of facilities’ pain management teams.
5 Require the program and the chief operating officer to assess and ensure corrective actions are taken to address each medical facility’s lack of progress in achieving compliance with the requirement to have a pain management team as mandated by the Jason Simcakoski Memorial and Promise Act.
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| 24-00596-129 | Healthcare Facility Inspection of the VA Oklahoma City Healthcare System in Oklahoma | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure all veterans and visitors, including those who require mobility assistance, have safe and accessible pathways to clinical areas during elevator repairs.
Closure Date:
2 The OIG recommends facility leaders ensure staff complete and document preventive maintenance for medical equipment.
Closure Date:
3 The OIG recommends the Chief of Staff and the Associate Director, Patient Care Services ensure staff record their attendance at meetings where staff monitor the communication of test result data.
Closure Date:
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| 24-00394-122 | Inspection of Select Vet Centers in Midwest District 3 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Evanston, La Crosse, and Milwaukee Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Evanston, Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
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3 District leaders and the Gary Area Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Gary Area, La Crosse, and Milwaukee Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
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5 District leaders and the Evanston, Gary Area, and Milwaukee Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
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6 District leaders and the La Crosse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
7 District leaders determine reasons why the closing of the Milwaukee Vet Center resulted in multiple communication failures, and ensure all clients are notified of the new location, the Vet Center Call Center has accurate information, and websites include correct location and phone number information.
Closure Date:
8 The Readjustment Counseling Service Chief Officer considers developing written guidance for vet center closure and temporary relocation processes including oversight responsibilities.
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| 24-00617-118 | Healthcare Facility Inspection of the VA Augusta Health Care System in Georgia | Healthcare Facility Inspection | ||
1 The OIG recommends the Under Secretary for Health evaluates facility leaders for appropriate supervisory behavior and professional communication and takes actions as needed.
Closure Date:
2 The OIG recommends the Under Secretary for Health determines whether the Veterans Integrated Service Network Director and other Veterans Integrated Service Network leaders were aware of, but did not address, facility leaders’ unprofessional behavior and communication, and takes actions as needed.
Closure Date:
3 The OIG recommends the Under Secretary for Health ensures the Veterans Integrated Service Network and facility directors oversee the inventory management system, resolve medical supply deficiencies, and monitor actions for sustained improvement.
4 The OIG recommends facility leaders develop action plans to ensure providers communicate test results to patients timely.
5 The OIG recommends the Under Secretary for Health directs the national VHA Quality and Patient Safety Program staff to review the facility’s quality management program and determine whether actions by facility and Veterans Integrated Service Network leaders effectively addressed system issues affecting patient safety, including nursing leaders’ lack of access to safety reports, and missed opportunities for institutional disclosures, and takes action as needed.
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| 24-02359-123 | Deficiencies in Emergency Care for a Female Veteran at Martinsburg VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Martinsburg VA Medical Center Director reviews communication between emergency department staff to ensure timely patient care coordination, and takes action as warranted.
2 The Martinsburg VA Medical Center Director ensures emergency department nurses monitor, assess, and document patient care as required by Veterans Health Administration and Martinsburg VA Medical Center policy, and monitors compliance.
3 The Martinsburg VA Medical Center Director ensures processes are in place to ensure blood transfusions are administered according to policy, and monitors compliance.
4 The Martinsburg VA Medical Center Director conducts a review of actions implemented as a result of the factfinding to include administrative actions and performance improvement plans and ensures quality of care concerns have been remediated, and takes action as warranted.
5 The Martinsburg VA Medical Center Director evaluates the functionality of emergency room equipment, including an exam table with footrests, for conducting gynecologic examinations with dignity and comfort, and takes action as warranted.
Closure Date:
6 The Martinsburg VA Medical Center Director reviews concerns related to fire department overtime practices, takes action as appropriate, and follows up to ensure compliance.
Closure Date:
7 The Martinsburg VA Medical Center Director reviews the transport delay for the abdominal pain patient, and takes action as appropriate.
8 The Martinsburg VA Medical Center Director reviews the factfinding related to transportation concerns, ensures an adequate review is conducted, and takes action as warranted.
Closure Date:
9 The Martinsburg VA Medical Center Director ensures all reported patient safety concerns related to emergency transport delays are investigated to identify root causes and contributing factors that require action to prevent future events.
Closure Date:
10 The Martinsburg VA Medical Center Director ensures clear guidance is in place for clinical and administrative staff on the use of facility emergent and non-emergent transport resources.
Closure Date:
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| 24-03777-113 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2024 | Review | ||
1 Reduce improper and unknown payments to below 10 percent for the Pension Program.
2 Reduce improper and unknown payments to below 10 percent for the Purchased Long-Term Services and Supports Program.
Closure Date:
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| 24-00604-121 | Healthcare Facility Inspection of the VA North Florida/South Georgia Veterans Health System in Gainesville | Healthcare Facility Inspection | ||
1 The OIG recommends the Associate Director of Operations ensures staff maintain, inspect, and test medical equipment.
2 The OIG recommends the Deputy Chief of Staff ensures staff secure all medications from unauthorized access.
3 The OIG recommends the Associate Director of Patient Care Services ensures staff appropriately store oxygen tanks.
4 The OIG recommends the Associate Director ensures staff clean all food storage areas.
5 The OIG recommends the Associate Director of Operations ensures staff remove expired supplies from storage areas.
6 The OIG recommends the Associate Director of Operations ensures staff mark equipment that needs repair and separate it from equipment available for use and remove dirty items from clean storage areas.
7 The OIG recommends facility leaders ensure sustained compliance with Joint Commission accreditation standards.
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| 24-02575-50 | Inspection of Information Security at the Battle Creek Healthcare System in Michigan | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure all vulnerabilities are identified and plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
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2 Implement a more effective baseline configuration process to ensure network devices are running authorized software that is configured to approved baselines and free of vulnerabilities.
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3 Improve the remediations reporting process for the Continuous Readiness in Information Security Program to verify that corrective actions are taken to fully mitigate vulnerabilities for biomedical devices at the Battle Creek facility.
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4 Implement improved physical access controls to restrict access to the server room and communications closets.
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5 Ensure network segmentation controls are applied to all network segments hosting special-purpose systems or medical devices.
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6 Implement improved, consistent environmental controls for network communications closets.
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| 23-02157-106 | Former Orlando VA Medical Center Executive Violated Ethics Rules | Administrative Investigation | ||
1 The Veterans Health Administration chief operating officer establishes a written policy or procedure to reasonably ensure that potential conflicts of interest or appearance of partiality concerns involving VHA employees are identified and remediated before contractor presentations to Veterans Integrated Service Network or facility leaders.
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2 The Veterans Integrated Service Network 8 director confirms that VA has initiated the process to seek recoupment of the critical skill incentive paid by VA to Ms. Skala that was attributable to a service period that she did not complete due to her retirement.
3 The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness directs a review to determine whether any VHA employee ranked GS‑15 or above awarded a critical skill incentive has left VA before completing their required service obligation, and, if so, whether VA has established a debt and initiated recoupment in the amount of the CSI attributable to the uncompleted period, and takes further corrective actions as warranted.
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| 24-01566-100 | Deficiencies in Trainee Onboarding, Physician Oversight, and a Root Cause Analysis at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 The Overton Brooks VA Medical Center Director reviews and monitors compliance with Veterans Health Administration health professions trainee onboarding requirements, and takes action as indicated.
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2 The Overton Brooks VA Medical Center Director makes certain that oversight of the intensive care unit physician credentialing and privileging process is completed prior to physicians being scheduled and providing patient care, and monitors compliance.
3 The Overton Brooks VA Medical Center Director ensures root cause analyses are completed according to Veterans Health Administration policy including team composition, root cause analysis process steps, and timeliness.
4 The Under Secretary for Health evaluates the additional root cause analysis concurrence step used within Veterans Health Administration medical centers to ensure alignment with National Center for Patient Safety guidance, and takes action as indicated.
Closure Date:
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15137