Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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).
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
8 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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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.
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10 The chief of staff ensures clinicians reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
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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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| 19-06125-218 | Mishandling of Veterans’ Sensitive Personal Information on VA Shared Network Drives | Review | ||
1 The assistant secretary for information and technology and the under secretary for benefits provide remedial training to users on the safe handling and storage of sensitive personal information on network drives.
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2 The assistant secretary for information and technology establishes technical controls to ensure users cannot store sensitive personal information on shared network drives.
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3 The assistant secretary for information and technology implements improved oversight procedures, including specific facility-level procedures, to ensure that sensitive personal information is not being stored on shared network drives.
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| 19-07040-243 | Comprehensive Healthcare Inspection Summary Report Fiscal Year 2018 | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that clinical managers consistently implement improvement actions recommended from peer review activities and monitor clinical managers’ compliance.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that physician utilization management advisors document the minimum required percentage of all inpatient stay reviews in the National Utilization Management Integration database and monitor physician advisors’ compliance.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that an interdisciplinary group or committee, that includes all required representatives, consistently reviews utilization management data and monitor committees’ compliance.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that clinical managers provide feedback about root cause analysis actions to the individuals or departments who reported the incidents and monitor clinical managers’ compliance.
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5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers report completed focused professional practice evaluations to an appropriate committee of the medical staff and monitor clinical managers’ compliance.
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6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers clearly delineate time frames in focused professional practice evaluations and monitor clinical managers’ compliance.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers include service-specific data in ongoing professional practice evaluations and monitor clinical managers’ compliance.
Closure Date:
8 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that clinical managers include specialty-specific elements in gastroenterology, pathology, nuclear medicine, and radiation oncology providers’ ongoing professional practice evaluations and monitor clinical managers’ compliance.
Closure Date:
9 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure that managers maintain a clean and safe environment throughout the facilities and monitor managers’ compliance.
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10 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that VA Police test panic alarms and document response times to alarm testing in locked mental health units and high-risk outpatient clinic areas and monitor VA Police compliance.
Closure Date:
11 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that facility managers install floor cushioning in locked mental health unit seclusion rooms and monitor facility managers’ compliance.
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12 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that facility managers annually review emergency operations plans and resource and asset inventories and monitor facility managers’ compliance.
Closure Date:
13 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, confirm that facility managers correct identified deficiencies from annual physical security surveys and monitor facility managers’ compliance.
Closure Date:
14 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, verify that controlled substances coordinators reconcile one-day’s dispensing from the pharmacy to every automated dispensing cabinet and returns to pharmacy stock from each dispensing area during controlled substances inspections and monitor controlled substances coordinators’ compliance.
Closure Date:
15 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, make certain that controlled substances coordinators refrain from routinely conducting monthly controlled substances inspections and monitor controlled substances coordinators’ compliance.
Closure Date:
16 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network Directors and facility senior leaders, ensure that facility managers conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitor facility managers’ compliance.
Closure Date:
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| 19-00346-241 | OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages, FY 2019 | National Healthcare Review | ||
1 The Under Secretary for Health ensures completion of all open action plans related to recommendations from previous iterations of this report.
Closure Date:
2 The Under Secretary for Health identifies a plan of action that will address the underlying causes of severe occupational staffing shortages identified in this report.
Closure Date:
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| 18-03979-204 | Oversight and Resolution of Home Loan Defaults | Audit | ||
1 The under secretary for benefits implements controls to identify and address unreported monthly loan status in the upgraded VA Loan Electronic Reporting Interface system and implement compensating controls in the interim.
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2 The under secretary for benefits ensures that loan servicers report when loss mitigation letters are sent and impose necessary regulatory infractions when required.
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3 The under secretary for benefits ensures post-audit and adequacy of servicing reviews are compiled and trended and generate key loan servicer performance statistics.
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4 The under secretary for benefits develops a plan to implement a formal tier-ranking system following the implementation of the upgraded VA Loan Electronic Reporting Interface system.
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| 18-05316-234 | Facility Hiring Processes and Leaders’ Responses Related to the Deficient Practice of a Radiologist at the Charles George VA Medical Center, Asheville, North Carolina | Hotline Healthcare Inspection | ||
1 The Charles George VA Medical Center Director verifies that facility managers adhere to Veterans Health Administration policy that outlines the credentialing and privileging process for licensed independent practitioners.
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2 The Charles George VA Medical Center Director and managers meet all requirements of state licensing boards reporting.
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3 The Charles George VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting of all adverse events to the Patient Safety Manager.
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4 The Charles George VA Medical Center Director confers with Human Resources regarding the actions taken by facility leaders and managers, related to the lack of oversight and failure to conduct credentialing and privileging per Veterans Health Administration requirements, and take administrative action(s) as necessary.
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| 19-07818-242 | Emergency Department Care of Intoxicated Patients and Those with Mental Health Conditions at the Louis Stokes Cleveland VA Medical Center, Ohio | Hotline Healthcare Inspection | ||
1 The Louis Stokes Cleveland VA Medical Center Director defines what elements are required for a medical screening exam to deem a patient medically stable prior to transfer to the Psychiatric Assessment and Observation Center.
Closure Date:
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15039