Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00011-255 | Comprehensive Healthcare Inspection of the James A. Haley Veterans' Hospital, Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
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2 The chief of staff ensures that service chiefs clearly define and share in advance the expectations, outcomes, and time limits for focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
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3 The facility director makes certain that the pharmacy or nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff compliance
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4 The facility director confirms providers complete military sexual trauma mandatory training no later than 90 days after assuming their position and monitors providers’ compliance.
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5 The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and assess understanding of the education provided and monitors clinicians’ compliance.
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6 The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
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7 The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
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| 19-05960-244 | Records Management Center Disclosed Third-Party Personally Identifiable Information to Privacy Act Requesters | Review | ||
1 The Under Secretary for Benefits implements the Veterans Benefits Administration’s commitment to update its Privacy Act release policy and begin redacting third-party personally identifiable information.
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2 The Under Secretary for Benefits ensures VA’s website is updated to reflect current Veterans Benefits Administration policy regarding release of third-party personally identifiable information.
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3 The Under Secretary for Benefits implements a plan to ensure the Records Management Center complies with requirements for mailing Privacy Act responses in accordance with VA Directive 6609.
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4 The Under Secretary for Benefits establishes a plan to ensure that Records Management Center management receives a report for any site visit of the Records Management Center completed by the Veterans Benefits Administration and takes corrective action as needed.
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5 The Records Management Center director implements a plan to improve quality reviews and ensures staff are held accountable for the accuracy of their Privacy Act releases.
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| 18-04682-256 | Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center, Dublin, Georgia | 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.
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2 The facility director ensures the patient safety manager includes all required content in each root cause analysis and monitors patient safety manager’s compliance.
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3 The director ensures the Intensive Care Unit/Cardiopulmonary Resuscitation Committee conducts a complete analysis of resuscitative episodes that includes all required elements and monitors committee’s compliance.
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4 The chief of staff ensures that service chiefs define and communicate expectations for focused professional practice evaluations in advance and maintain appropriate documentation of the process and monitors service chiefs’ compliance.
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5 The chief of staff makes certain that the service chiefs document the focus professional practice evaluation results in the practitioner profiles and monitors service chiefs’ compliance.
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6 The chief of staff ensures that service chiefs include the minimum-required specialty-specific criteria for professional practice evaluations of gastroenterology and nuclear medicine practitioners and monitors service chiefs’ compliance.
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7 The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
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8 The chief of staff makes certain that the Medical Executive Committee documents its decision to recommend privileges based on professional practice evaluation results when recommending approval of privileges to the director and monitors committee’s compliance.
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9 The facility director reports privileging actions taken by the facility to the National Practitioner Data Bank and monitors compliance.
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10 The associate director ensures that the VA Police regularly test panic alarms and document results and monitors staff compliance.
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11 The facility director makes certain that controlled substances program staff reconcile one day’s stocking/refilling from the pharmacy to each dispensing area and one day’s return of stock to pharmacy from every automated dispensing unit during monthly inspections and monitors coordinator’s compliance.
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12 The facility director confirms that the controlled substances coordinator ensures that written and electronic controlled substance orders have been verified and assessed for documentation of two signatures for any waste of partial doses and monitors coordinator’s compliance.
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13 The facility director makes certain that the controlled substances coordinator validates that monthly inventories of controlled substances are conducted as required in the pharmacy and monitors coordinator’s compliance.
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14 The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
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15 The chief of staff confirms that the military sexual trauma coordinator communicates the status of military sexual trauma-related issues, services, and initiatives to facility leadership and monitors coordinator’s compliance.
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16 The chief of staff confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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17 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
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18 The facility director ensures the appointment of a women’s health medical director or clinical champion.
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19 The facility director ensures the facility has a Women Veterans Health Committee that has an active charter, meets at least quarterly, and reports to leadership with signed minutes and monitors committee’s compliance.
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20 The facility director makes certain that facility staff implement a process to track and monitor cervical cancer screenings, results reporting, and follow-up care and monitors assigned staff compliance.
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21 The chief of staff ensures patient notification of abnormal cervical results are completed within the required time frame and monitors compliance.
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22 The chief of staff makes certain that a backup call schedule is maintained for urgent care center providers and monitors compliance.
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| 19-07247-251 | FY 2019 Audit of VA’s Compliance under the DATA Act of 2014 | Audit | ||
1 We recommend the Assistant Secretary for Management and Chief Financial Officer continue the system modernization efforts that provide VA with the capability to generate the required DATA Act reporting files containing the necessary elements to meet compliance with the DATA Act. Ensure the modernization will provide the following:
a. Accurate reporting of object class, program activity codes, program activity names and all other elements required by the DATA Act.
b. Store award identification to allow VA to be able to develop a File C and reconcile the File C to both summary level data (Files A and B) and award level data (File D). The reconciliations should be performed prior to the quarterly certification.
c. Report reconciliation with its subsidiary systems.
d. A mechanism to ensure transactions are reported that currently may be excluded due to the use of 1358s.
e. Standardize data field use to allow for management to record an award ID across financial and supporting systems.
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2 We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure a DQP is finalized and implemented for future DATA Act submissions which meets the requirements for DATA Act reporting. In addition, the Office of Management, Office of Internal Control, and the Office of Enterprise Risk Management should ensure that the DQP supports the annual assurance statement and quarterly certification.
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3 We recommend the Assistant Secretary for Management and Chief Financial Officer Implement a grants management solution that will be either integrated with the new financial system or interface into it once completed. The VA should identify a grants management solution that can be implemented across all of VA’s grant programs.
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4 We recommend the Assistant Secretary for Management and Chief Financial Officer Work with the SAO and component level SAO’s to ensure that all certifications are signed, dated by the component SAO and received prior to the submission date.
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5 We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure that the four CFDA programs (64.014, 64.015, 64.026, and 64.024) report obligations according to the definitions established for FABS reporting or obtain OMB and Treasury’s approval for any deviations.
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6 We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure the Office of Budget implements monitoring controls over CFDA numbers to ensure any CFDA numbers that require activation are identified and activated promptly to avoid interruptions in expenditure reporting.
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7 We recommend the Assistant Secretary for Management and Chief Financial Officer Research the basis for the delays in reporting expenditure data for FABS for the VHA Veterans Prescription Service program (CFDA # 64.012) and implement a corrective action plan for timely reporting going forward. The VA PMO should also seek an exemption from OMB and Treasury regarding the reporting delays for the program if no viable solutions are identified to mitigate the timing delays.
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8 We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain and document guidance from Treasury and OMB on the proper treatment of payments to contractors for VA’s Veterans Choice Program as either contract award (File D1) or financial assistance (File D2).
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9 We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain and document guidance from Treasury and OMB regarding inclusion of payroll and contract costs in the FABS (File D2) and the duplication of the same contract costs in the FPDS-NG (File D1).
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10 We recommend the Assistant Secretary for Management and Chief Financial Officer Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for FABS reporting. The internal controls should ensure the following:
a. Excluded payments not reported due to zip code issues are researched, cleared, and reported in VBA’s sub certification.
b. The default code “90” for Congressional District is not used when the county or zip code are unknown; instead, perform research to obtain the required data.
c. Support from Treasury and OMB on the proper reporting of face amount of insurance in its FABS submissions.
d. The information submitted for each data element is adequately supported and readily available.
e. All data elements are reported in compliance with the definitions established by the DAIMS.
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11 We recommend the Assistant Secretary for Management and Chief Financial Officer Improve review procedures prior to submission to identify errors and ensure all transactions are included in procurement and financial assistance data.
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12 We recommend the Assistant Secretary for Management and Chief Financial Officer Perform research to determine the extent to which 1358 transactions are not reported for File D1 and develop solutions.
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13 We recommend the Assistant Secretary for Management and Chief Financial Officer Develop solutions and continue system modernization efforts to reduce the use of the default object class. Research and develop program activity crosswalk for medical services.
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14 We recommend the Assistant Secretary for Management and Chief Financial Officer Strengthen procedures over the process to report all program activity names and program activity codes that are reported in the quarterly OMB MAX Collect Exercise in accordance with the latest Budget Data request requirements.
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15 We recommend the Assistant Secretary for Management and Chief Financial Officer Reinforce guidance for Contracting Officers concerning areas where exceptions were noted in DATA Act reporting.
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16 We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain OMB and Treasury approval for aggregating and reporting transactions based on beneficiary address. Ensure controls around the aggregation process are implemented and operating effectively.
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| 19-07095-253 | Ophthalmology Equipment and Related Concerns at the James A. Haley Veterans’ Hospital, Tampa, Florida | Hotline Healthcare Inspection | ||
1 The James A. Haley Veterans’ Hospital Director ensures that Biomedical Section staff complete work order documentation accurately as required by facility policy and in accordance with Veterans Health Administration guidelines.
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2 The James A. Haley Veterans’ Hospital Director enhances efforts to improve equipment corrective maintenance completion times and that Biomedical Section staff communicate the status of repairs with end users.
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3 The James A. Haley Veterans’ Hospital Director takes action to improve the timeliness of eyeglass purchase order processing.
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4 The James A. Haley Veterans’ Hospital Director ensures that Prosthetics and Sensory Aid Service resolves the open eyeglass purchase order requests.
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| 19-00018-252 | Comprehensive Healthcare Inspection of the Fargo VA Health Care System, North Dakota | 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.
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2 The chief of staff ensures that the Medical Executive Committee evaluates providers’ reprivileging requests based on
ongoing professional practice evaluation results, and meeting minutes consistently reflect the decision to recommend
continuation of ongoing privileges and monitors committee’s compliance.
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3 The chief of staff ensures providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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4 The facility director makes certain that the emergency department is staffed by a minimum of two registered nurses during all hours of operation and monitors the department’s compliance.
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5 The chief of staff makes certain that the chief of emergency department maintains a written backup call schedule for emergency department providers and monitors emergency department chief’s compliance.
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| 18-04451-06 | The Impact of VA Allowing Government Agencies to Be Excluded from Temporary Price Reductions on Federal Supply Schedule Pharmaceutical Contracts | Review | ||
1 Develop and implement a policy that prohibits restricted and agency-specific temporary price reductions on Federal Supply Schedule contracts, including procedures on how to process requests for temporary price reductions to ensure inclusion of all Federal Supply Schedule users.
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2 Consult with VA’s Office of General Counsel regarding the legality of confidentiality provisions in Federal Supply Schedule contract modifications for temporary price reductions, specifically whether they are consistent with competition mandates of the Federal Acquisition Regulation.
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3 Develop a written policy for temporary price reductions that exceed one year and are subject to renewal, specifically addressing how such long-term temporary price reductions should be considered when determining fair and reasonable pricing on contract extension or renewals.
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4 Consult with appropriate legal authorities, including the Department of Justice, regarding the legality of unilateral Federal Supply Schedule contract modifications for temporary price reductions.
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| 18-04968-249 | Failures Implementing Aspects of the VA Accountability and Whistleblower Protection Act of 2017 | Review | ||
1 The Assistant Secretary for Accountability and Whistleblower Protection directs a review of the Office of Accountability and Whistleblower Protection’s compliance with the VA Accountability and Whistleblower Protection Act of 2017 requirements in order to ensure proper implementation and eliminate any activities not within its authorized scope.
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2 The VA Secretary rescinds the February 2018 Delegation of Authority and consults with the Assistant Secretary for Accountability and Whistleblower Protection, the VA Office of General Counsel, and other appropriate parties to determine whether a revised delegation is necessary, and if so, ensures compliance with statutory requirements.
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3 The Assistant Secretary for Accountability and Whistleblower Protection, in consultation with the Office of General Counsel, Office of Inspector General, Office of the Medical Inspector, and the Office of Resolution Management establishes comprehensive processes for evaluating and documenting whether allegations, in whole or in part, should be handled within the Office of Accountability and Whistleblower Protection or referred to other VA entities for potential action or referred to independent offices such as the Office of Inspector General.
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4 The Assistant Secretary for Accountability and Whistleblower Protection makes certain that policies and processes are developed, in consultation with the VA Office of General Counsel and Office of Resolution Management, to consistently and promptly advise complainants of their right to bring allegations of discrimination through the Equal Employment Opportunity process.
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5 The Assistant Secretary for Accountability and Whistleblower Protection ensures that the divisions of the Office of Accountability and Whistleblower Protection adopt standard operating procedures and related detailed guidance to make certain they are fair, unbiased, thorough, and objective in their work.
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6 The VA General Counsel updates VA Directive 0700 and VA Handbook 0700 with revisions clarifying the extent to which VA Directive 0700 and VA Handbook 0700 apply to the Office of Accountability and Whistleblower Protection, if at all.
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7 The Assistant Secretary for Accountability and Whistleblower Protection assigns a quality assurance function to an entity positioned to review Office of Accountability and Whistleblower Protection divisions’ work for accuracy, thoroughness, timeliness, fairness, and other improvement metrics.
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8 The Assistant Secretary for Accountability and Whistleblower Protection directs the establishment of a training program for all relevant personnel on appropriate investigative techniques, case management, and disciplinary actions.
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9 The VA Secretary, in consultation with the VA Office of General Counsel, provides comprehensive guidance and training reasonably designed to instill consistency in penalties for actions taken pursuant to 38 U.S.C. §§ 713 and 714.
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10 The VA Secretary ensures the provision of comprehensive guidance and training to relevant disciplinary officials to maintain compliance with the mandatory adverse action criteria outlined in 38 U.S.C. § 731.
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11 The Assistant Secretary for Accountability and Whistleblower Protection makes certain that in any disciplinary action recommended by the Office of Accountability and Whistleblower Protection, all relevant evidence is provided to the VA Secretary (or the disciplinary officials designated to act on the Secretary’s behalf).
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12 The Assistant Secretary for Accountability and Whistleblower Protection implements safeguards consistent with statutory mandates to maintain the confidentiality of employees that make submissions, including guidelines for communications with other VA components.
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13 The Assistant Secretary for Accountability and Whistleblower Protection leverages available resources, such as VA’s National Center for Organizational Development and the Office of Resolution Management, to conduct an organizational assessment of Office of Accountability and Whistleblower Protection employee concerns and develop an appropriate action plan to strengthen Office of Accountability and Whistleblower Protection workforce engagement and satisfaction.
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14 The Assistant Secretary for Accountability and Whistleblower Protection develops a process and training for the Triage Division staff to identify and address potential retaliatory investigations.
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15 The Assistant Secretary for Accountability and Whistleblower Protection collaborates with the Assistant Secretary for Human Resources and Administration, and the VA Secretary to develop performance plan requirements as required by 38 U.S.C. § 732.
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16 The Assistant Secretary for Accountability and Whistleblower Protection ensures the implementation of whistleblower disclosure training to all VA employees as required under 38 U.S.C. § 733.
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17 The VA Secretary makes certain supervisors’ training is implemented as required under § 209 of the VA Accountability and Whistleblower Protection Act of 2017.
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18 The Assistant Secretary for Accountability and Whistleblower Protection confers with the VA Office of General Counsel to develop processes for collecting and tracking justification information related to proposed disciplinary action modifications consistent with 38 U.S.C. § 323(f)(2).
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19 The VA Secretary in consultation with the Office of General Counsel and the Assistant Secretary for Accountability and Whistleblower Protection ensures compliance with the 60-day reporting requirement in 38 U.S.C. § 323(f)(2) consistent with congressional intent.
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20 The Assistant Secretary for Accountability and Whistleblower Protection develops or enhances database systems to provide the capability to track all data required by the VA Accountability and Whistleblower Protection Act of 2017.
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21 In consultation with the VA Office of General Counsel, the Assistant Secretary for Accountability and Whistleblower Protection completes the publication of Systems of Records Notices for all systems of records maintained by the Office of Accountability and Whistleblower Protection, and adopts procedures reasonably designed to ensure that the Office of Accountability and Whistleblower Protection does not create additional systems of records without complying with the requirements of the Privacy Act of 1974.
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22 The Assistant Secretary for Accountability and Whistleblower Protection consults with the VA Chief Freedom of Information Act Officer to ensure adequate training and staffing of the Office of Accountability and Whistleblower Protection’s Freedom of Information Act Office, and establishes procedures to comply with FOIA requirements including timeliness.
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| 19-00035-247 | Comprehensive Healthcare Inspection of the VA Texas Valley Coastal Bend Health Care System, Harlingen, Texas | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that clinical managers define the focused professional practice evaluation process in advance and monitors clinical managers’ compliance.
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2 The chief of staff confirms that clinical managers ensure ongoing professional practice evaluations include service-specific criteria and monitors clinical managers’ compliance.
Closure Date:
3 The chief of staff makes certain that service chiefs collect and review ongoing professional practice evaluation data and that the facility’s Clinical Executive Board reviews the data in the consideration to recommend continuation of provider privileges, and monitors compliance.
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4 The chief of staff makes certain that clinical managers include required specialty-specific criteria in ongoing professional practice evaluations for solo/few gastroenterology practitioners and monitors clinical managers’ compliance.
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5 The associate director ensures that facility engineers conduct weekly electrical system inspections and monitors compliance.
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6 The facility director makes certain that controlled substances inspection staff reconcile one day’s stocking/refilling from the pharmacy to each dispensing area and one day’s return of stock to pharmacy and that the controlled substances coordinator evaluates and maintains supporting documentation, and the facility director monitors coordinator’s compliance.
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7 The facility director ensures that the controlled substances inspectors verify documentation for two signatures for any waste of partial doses and monitors controlled substances inspectors’ compliance.
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8 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
9 The chief of staff makes certain that clinicians assess and document the patient/caregiver’s understanding of education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
10 The chief of staff ensures clinicians reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
Closure Date:
11 The chief of staff confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
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| 18-04608-212 | VA’s Management of Mobile Devices Generally Met Information Security Standards | Audit | ||
1 The OIG recommended the assistant secretary for the Office of Information and Technology enforce blacklisting or formally assess and document the approach of using training as the mitigating control to prevent users from downloading and using non-VA-approved applications.
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2 The OIG recommended the assistant secretary for the Office of Information and Technology use configuration management tools to prevent premature or late updating of mobile devices or develop proactive policies and procedures to ensure users do not update mobile devices and applications until after the mobile device management team has conducted testing.
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3 The OIG recommended the assistant secretary for the Office of Information and Technology validate that users of mobile devices are completing the required annual Mobile Training: Security of Apps on iOS Devices before user accounts are activated.
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14957