Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-04859-196 | Insufficient Oversight of VA’s Undelivered Orders | Audit | ||
1 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure relevant staff review and reconcile open orders to identify and deobligate excess funds for completed, canceled, or orders recorded more than once, and ensure the relevant staff follow existing policy regarding required reviews of open obligations.
Closure Date:
2 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure that obligation policy includes specific time frames for effective interdepartmental communication to ensure timely identification of funds that are no longer needed for their original purpose and could be deobligated.
Closure Date:
3 The assistant secretary for management and chief financial officer should develop a process for monitoring performance across the Department regarding reconciliation of open orders and develop a plan to share results with appropriate officials for their action.
Closure Date:
4 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with existing policy, which requires that obligations be adjusted when actual costs of goods and services are known to be less than the initially recorded amount.
Closure Date:
5 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with policy, which requires that obligations be supported by sufficient documentary evidence that substantiates the validity and proper authorization of obligations and that the evidence be retained and readily available upon request.
Closure Date:
6 The Veterans Health Administration executive director for procurement should ensure timely modifications or closing of contracts, when applicable, to allow for the deobligation of funds no longer required.
Closure Date:
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| 18-06504-27 | Comprehensive Healthcare Inspection of the Kansas City VA Medical Center, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that clinicians peer review all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
Closure Date:
2 The chief of staff verifies that clinicians complete peer reviews of all completed suicides that occur within seven days after discharge from inpatient mental health treatment or residential care units and monitors clinicians’ compliance.
Closure Date:
3 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
4 The associate director ensures electronic safety data sheets are readily accessible to employees and monitors compliance.
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5 The associate director confirms that unit managers store clean and dirty medical equipment separately and monitors managers’ compliance.
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6 The associate director ensures the mental health nursing station prevents unauthorized entry and monitors compliance.
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7 The associate director ensures that the hazard vulnerability analysis and the emergency operations plan are approved by executive leadership and monitors compliance.
Closure Date:
8 The facility director ensures that controlled substances inspection program staff complete reconciliation of one random day’s return of stock to the pharmacy from every automated dispensing cabinet during monthly inspections and monitors program staff compliance.
Closure Date:
9 The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
10 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
11 The chief of staff ensures clinicians reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
Closure Date:
12 The chief of staff makes certain that the Women Veterans Health Committee includes all required core members and monitors the committee’s compliance.
Closure Date:
13 The chief of staff ensures the Women Veterans Health Committee reports to executive leaders and monitors the committee’s compliance.
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14 The chief of staff makes certain that the emergency department director maintains a backup call schedule for emergency department providers and monitors the director’s compliance.
Closure Date:
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| 19-00024-39 | Comprehensive Healthcare Inspection of the VA Manila Outpatient Clinic, Pasay City, Philippines | Comprehensive Healthcare Inspection Program | ||
1 The chief medical officer ensures that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
2 The facility director makes certain that controlled substances inspectors perform a complete count of the pharmacy’s controlled substances physical inventory during monthly inspections and monitors inspectors’ compliance.
Closure Date:
3 The chief medical officer ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with facility leaders and monitors coordinator’s compliance.
Closure Date:
4 The chief medical officer makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data.
Closure Date:
5 The chief medical officer ensures providers complete comprehensive diagnostic evaluations within the required time frame for all new patients referred for mental health services for military sexual trauma and monitors providers’ compliance.
Closure Date:
6 The chief medical officer makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
7 The chief medical officer ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
Closure Date:
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| 19-06562-30 | Alleged Deficiencies in Oncology Psychosocial Distress Screening and Root Cause Analysis Processes at a Facility in VISN 15 | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Medical 15 Facility Director conducts an evaluation of radiation oncology clinic mental health consultation and treatment program needs and adjusts mental health provider coverage as warranted.
Closure Date:
2 The Veterans Integrated Service Network Medical 15 Facility Director ensures that all components of the oncology service psychosocial distress screening standard operating procedures include screening frequency consistent with National Comprehensive Cancer Network’s ideal standards.
Closure Date:
3 The Veterans Integrated Service Network Medical 15 Facility Director guarantees that the patient safety program maintains effective processes to track action items to completion and monitors compliance.
Closure Date:
4 The Veterans Integrated Service Network Medical 15 Facility Director ensures that staff complete Suicide Behavior and Overdose Reports and Behavioral Health Autopsies, as required by the Veterans Health Administration.
Closure Date:
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| 19-00049-43 | Comprehensive Healthcare Inspection of the VA Butler Health Care Center, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that the Medical Executive Committee considers and documents the deliberation of professional practice data prior to granting privileges and monitors committee’s compliance.
Closure Date:
2 The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
3 The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided and monitors clinicians’ compliance.
Closure Date:
4 The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
Closure Date:
5 The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
Closure Date:
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| 18-02300-236 | Delays and Deficiencies in Management of Selected Radiology and Nuclear Medicine Outpatient Exams | Audit | ||
1 Ensure facility staff evaluate scheduling workload and that medical support assistant staffing is adequately distributed for scheduling radiology exam requests in a timely manner.
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2 Provide formal guidance to facilities for establishing clinic management models for adequate radiology resources, including staffing and equipment.
Closure Date:
3 Ensure facility radiology and nuclear medicine services monitor exam requests pending greater than seven days and address them in a timely manner.
Closure Date:
4 Confirm with each facility director that they reviewed each record and took appropriate action as they deemed necessary for the three completed requests with additional follow-up care needs.
Closure Date:
5 Develop and implement a plan for improved radiology and nuclear medicine oversight at the Veterans Integrated Service Network level.
Closure Date:
6 Implement a mechanism to routinely audit canceled exam requests, ensuring the requests are in accordance with VA radiology and nuclear medicine policies and procedures for canceling exam requests, and taking corrective actions as needed based on audit results.
Closure Date:
7 Create a method to notify radiology and nuclear medicine leaders at all VA medical facilities when guidance is released. The method should be streamlined with maximum distribution and ensure receipt and acknowledgment by affected radiology and nuclear medicine leaders.
Closure Date:
8 Confirm with each facility director that they review each record and take appropriate action for five of the six canceled requests with outstanding exam needs.
Closure Date:
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| 19-00023-29 | Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System, Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
2 The chief of staff confirms that clinical managers ensure that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors managers’ compliance.
Closure Date:
3 The associate director for Patient Care Services ensures staff remove expired medications from service and monitors staff compliance.
Closure Date:
4 The associate director for Patient Care Services makes certain that managers store clean and dirty medical equipment separately and monitors managers’ compliance.
Closure Date:
5 The associate director makes certain staff use privacy screens on all computer monitors located in public areas and monitors staff compliance.
Closure Date:
6 The associate director ensures that the Leeward Oahu VA Clinic waiting room carpet is replaced.
Closure Date:
7 The chief of staff ensures that Leeward Oahu VA Clinic staff secure laboratory transport boxes containing personally identifiable information and monitors staff compliance.
Closure Date:
8 The facility director ensures that controlled substances inspectors verify controlledsubstances orders for five random dispensing activities during monthly area inspectionsand monitors inspectors’ compliance.
Closure Date:
9 The chief of staff confirms that mental health and primary care providers completemilitary sexual trauma mandatory training within the required time frame and monitorsproviders’ compliance.
Closure Date:
10 The chief of staff confirms that the Women Veterans Health Committee is comprised of required members and monitors the committee’s compliance.
Closure Date:
11 The chief of staff makes certain that program managers collect and track cervical cancer screening notification, results reporting, and follow-up care data and monitors program managers’ compliance.
Closure Date:
12 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
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| 19-00014-33 | Comprehensive Healthcare Inspection of the Northern Arizona VA Health Care System, Prescott, Arizona | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
2 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
3 The facility director ensures all root cause analyses actions are fully implemented by assigned staff and monitors the assigned staff’s compliance.
Closure Date:
4 The facility director ensures the Cardiopulmonary Resuscitation Committee conducts complete analyses of resuscitative episodes by reviewing required elements and monitors the committee’s compliance.
5 The chief of staff makes certain that the Radiology Service chief includes the required nuclear medicine-specific criteria for ongoing professional practice evaluations of nuclear medicine providers and monitors the chief’s compliance.
6 The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
7 The facility director makes certain that controlled substances program staff complete reconciliation of one random day’s return of stock to pharmacy from every automated dispensing cabinet during inspections and monitors controlled substances program staff compliance.
8 The facility director ensures controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
9 The facility director ensures that the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training.
Closure Date:
10 The facility director makes certain that the military sexual trauma coordinator establishes and monitors informational outreach and monitors the coordinator’s compliance.
Closure Date:
11 The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with leadership and monitors the coordinator’s compliance.
Closure Date:
12 The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
Closure Date:
13 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
14 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
15 The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
Closure Date:
16 The facility director ensures the Women Veterans Health Committee maintains an active charter, meets at least quarterly, and reports to executive leaders with signed minutes and monitors the committee’s compliance.
Closure Date:
17 The chief of staff confirms that the women veterans program manager implements a quality assurance process to include tracking of data for cervical cancer screening and results and monitors the manager’s compliance.
Closure Date:
18 The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
19 The chief of staff directs the acute care medical director to ensure that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
Closure Date:
20 The facility director makes certain that the chief of Pharmacy ensures highly concentrated oral liquid opioid medications are not stored in patient care areas for patient safety and monitors the chief’s compliance.
Closure Date:
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| 19-00019-26 | Comprehensive Healthcare Inspection of the Sioux Falls VA Health Care System, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
2 The chief of staff ensures that the imaging service chief includes the minimum required specialty-specific criteria for focused professional practice evaluations of nuclear medicine practitioners and monitors imaging service chief’s compliance.
Closure Date:
3 The associate director confirms that facility managers replace or remove damaged furnishings and wheelchairs from service and monitors compliance.
Closure Date:
4 The facility director makes certain that the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substance orders and monitors inspectors’ compliance.
Closure Date:
5 The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
6 The chief of staff makes certain that clinicians provide and document patient and/or caregivers education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
7 The facility director ensures the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
Closure Date:
8 The facility director makes certain that the emergency department is staffed with a minimum of two registered nurses during all hours of operation and monitors compliance.
Closure Date:
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| 18-00711-211 | Financial Controls and Payments Related to VA-Affiliated Nonprofit Corporations: Boston VA Research Institute | Audit | ||
1 The under secretary for health confer with VA Office of General Counsel and the VA Boston Healthcare System Human Resources Office to determine if administrative actions should be taken concerning VA Boston Healthcare System officials responsible for the $1.6 million in inappropriate payments to the Boston VA Research Institute.
Closure Date:
2 The under secretary for health determine appropriate actions for the inappropriate overpayments, made by VA Boston Healthcare System officials, associated with salaries and fringe benefits for ineligible Boston VA Research Institute administrative staff, as well as duplicate employer retirement contribution payments.
Closure Date:
3 The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Human Resources Office develops procedures to require reviews of VA-affiliated nonprofit corporation Intergovernmental Personnel Act agreements for compliance with VA Handbook 5005, Staffing, prior to approval.
Closure Date:
4 The VA Boston Healthcare System director determine appropriate actions to ensure the VA Boston Healthcare System Research and Development Budget Office develops procedures for adequate review of VA-affiliated nonprofit corporation invoices to prevent duplicate payments in accordance with VA financial policy prior to approval.
Closure Date:
5 The VA Boston Healthcare System director determine appropriate actions to ensure procedures are developed that require the VA Boston Healthcare System Research and Development Budget Office supervisor to conduct periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
Closure Date:
6 The VA Boston Healthcare System director establish procedures to ensure research and development budget office staff review VA-affiliated nonprofit corporation invoices to make certain services were performed or the goods have been received in accordance with the agreement prior to payment.
Closure Date:
7 The VA Boston Healthcare System director establish procedures to ensure the Research and Development Budget Office supervisor conducts periodic reviews of VA-affiliated nonprofit corporation invoices authorized for payment by staff to prevent improper payments, as required by VA Financial Policies and Procedures, volume VIII, chapter 1A.
Closure Date:
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14957