Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-01836-185 | Sole-Source Service Contracting at Regional Procurement Office West Needs Improvement | Review | ||
1 The OIG recommended the Executive Director, VHA Procurement, ensure awareness of approval procedures and the requirement to prepare a written justification and approval document for sole-source contracts,
Closure Date:
2 The OIG recommended the Executive Director, VHA Procurement, establish procedures to help ensure all justification and approval documents are prepared and approved by the appropriate authority.
Closure Date:
3 The OIG recommended the Executive Director, VHA Procurement, review the actions of contracting personnel involved in the cited contracts and determine whether administrative actions are warranted.
Closure Date:
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| 18-01836-184 | Sole-Source Service Contracting at Regional Procurement Office East Needs Improvement | Review | ||
1 The OIG recommended that the executive director, VHA Procurement ensure awareness of approval procedures and the requirement to prepare a writtenjustification and approval document for sole-source contracts.
Closure Date:
2 The OIG recommended that the executive director, VHA Procurement establish procedures to help ensure all justification and approval documents areprepared and approved by the appropriate authority.
Closure Date:
3 The OIG recommended that the executive director, VHA Procurement review the actions of contracting personnel involved in the cited contracts anddetermine whether administrative actions are warranted.
Closure Date:
4 The OIG recommended that the executive director, VHA Procurement establish formal coordination with the requiring activity to ensure adequate time isallotted for soliciting and awarding recurring services competitively.
Closure Date:
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| 18-05258-193 | Security and Access Controls for the Beneficiary Fiduciary Field System Need Improvement | Audit | ||
1 The assistant secretary for information and technology, in conjunction with the under secretary for benefits, reevaluate the risk determination for the Beneficiary Fiduciary Field System and determine if the system should be set to a security categorization level.
Closure Date:
2 The assistant secretary for information and technology, in conjunction with the under secretary for benefits, perform a risk assessment of access levels to beneficiary and fiduciary records, based upon the least privilege principle, and regularly review access to ensure that principle is enforced.
Closure Date:
3 The assistant secretary for information and technology ensures audit logs within the Beneficiary Fiduciary Field System allow for management tracking of end-user access in order to reduce unauthorized browsing and the risk of data theft due to malicious activity.
Closure Date:
4 The under secretary for benefits ensures field examiners submit reports with a cursory lock engaged to protect their data integrity and to prevent separation of duties issues.
Closure Date:
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| 18-01836-183 | Problems Were Identified on One Regional Procurement Office Central Ambulance Service Contract | Review | ||
1 The OIG recommended that the executive director, VHA Procurement ensure awareness of approval procedures for justification and approval documents for sole source contracts.
Closure Date:
2 The OIG recommended that the executive director, VHA Procurement establish formal coordination with the requiring activity to ensure adequate time is allotted for soliciting and awarding recurring services competitively.
Closure Date:
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| 18-05663-189 | Accuracy of Claims Decisions Involving Conditions of the Spine | Review | ||
1 Implement a plan to conduct a focused analysis of claims processor compliance with the requirements set forth by recent court decisions regarding examiner opinions and formulate a plan to review and take corrective action on affected claims if deemed necessary based on the results of that review.
Closure Date:
2 Develop a plan to update the rating schedule to establish more objective criteria for each level of evaluation for peripheral nerves.
Closure Date:
3 Review all sections of the procedures manual related to peripheral nerve disability evaluations and develop a plan to make updates and clarifications where applicable.
Closure Date:
4 Review the disability benefits questionnaire forms for conditions of the spine and determine whether updates are needed to help ensure more accurate and consistent claims decisions.
Closure Date:
5 Update the Evaluation Builder tool to help users provide more accurate, comprehensive, and consistent information for claims decisions involving the spine and peripheral nerves.
Closure Date:
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| 17-05251-194 | National Review of Hospice and Palliative Care at the Veterans Health Administration | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health ensures the development and implementation of a consistent and standardized approach for hospice and palliative care documentation, consult management, and coding.
Closure Date:
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| 17-03399-200 | Facility Leaders’ Oversight and Quality Management Processes at the Gulf Coast VA Health Care System in Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 16 Director oversees implementation of recommendations directed to the Gulf Coast VA Health Care System Director.
Closure Date:
2 The Gulf Coast VA Health Care System Director ensures that providers with previous licensure issues or malpractice cases meeting the Veterans Health Administration indicated threshold for Veterans Integrated Service Network Chief Medical Officer review, are approved by the Veterans Integrated Service Network Chief Medical Officer prior to appointment of the provider to the medical staff as required by Veterans Health Administration policy and monitors compliance.
Closure Date:
3 The Gulf Coast VA Health Care System Director ensures that Focused and Ongoing Professional Practice Evaluations are completed in accordance with Veterans Health Administration policy and monitors compliance.
Closure Date:
4 The Gulf Coast VA Health Care System Director ensures that actions are taken to ensure processes are followed to review and report providers, when indicated, to the National Practitioner Data Bank and state licensing boards in the timeframe required by Veterans Health Administration policy and monitors compliance.
Closure Date:
5 The Gulf Coast VA Health Care System Director reviews the circumstances surrounding the failure to report the surgeon to all licensing boards in states where the surgeon held active licenses in December 2017 and takes action, if necessary.
Closure Date:
6 The Gulf Coast VA Health Care System Director ensures that the Executive Committee of the Medical Staff’s meeting minutes provide sufficient detail to allow tracking of medical management decisions and problem solving and monitors compliance.
Closure Date:
7 The Gulf Coast VA Health Care System Director determines the scope of previously administratively closed incomplete notes in patient electronic health records that have been administratively closed to ensure compliance with Veterans Health Administration policy and monitors compliance.
Closure Date:
8 The Gulf Coast VA Health Care System Director tracks and monitors the process used to administratively close incomplete electronic health record notes by providers who no longer work at the Gulf Coast VA Health Care System.
Closure Date:
9 The Gulf Coast VA Health Care System Director ensures and monitors that protected information contained in the Facility Surgical Workgroup minutes is maintained on a secure intranet site in alignment with Veterans Health Administration policy.
Closure Date:
10 The Gulf Coast VA Health Care System Director confirms that patients’ care whose death occurred within 30 days of a surgical procedure are reviewed and monitors compliance.
Closure Date:
11 The Gulf Coast VA Health Care System Director ensures that required staff maintain basic life support and advanced cardiac life support certification as required by Veterans Health Administration policy and monitors compliance.
Closure Date:
12 The Gulf Coast VA Health Care System Director makes sure that required Gulf Coast Health Care System services submit monthly basic life support and advanced cardiac life support compliance reports to the Critical Care Committee.
Closure Date:
13 The Gulf Coast VA Health Care System Director verifies that monthly basic life support and advanced cardiac life support compliance reports are provided to the Executive Committee of the Medical Staff as required by Gulf Coast VA Health Care System policy and monitors for compliance.
Closure Date:
14 The Gulf Coast VA Health Care System Director makes sure that Patient Safety Committee meeting minutes reflect a discussion of patient safety activities as required by Gulf Coast VA Health Care System policy and monitors compliance.
Closure Date:
15 The Gulf Coast VA Health Care System Director makes certain that past and future adverse events are reported to the patient safety manager as defined in Gulf Coast Health Care System policy and monitors compliance.
Closure Date:
16 The Gulf Coast VA Health Care System Director ensures that at least one proactive risk assessment is completed every 18 months for The Joint Commission accredited programs as required by Veterans Health Administration policy and monitors compliance.
Closure Date:
17 The Gulf Coast VA Health Care System Director makes certain that an effective process is in place to identify and review cases where an institutional disclosure may be indicated and monitors compliance.
Closure Date:
18 The Gulf Coast VA Health Care System Director reviews the eight identified events that met criteria for consideration of an institutional disclosure as required by Veterans Health Administration policy and takes action as warranted.
Closure Date:
19 The Gulf Coast VA Health Care System Director ensures that Administrative Investigation Boards are completed within the 45-calendar day timeframe required by Veterans Health Administration policy and monitors compliance.
Closure Date:
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| 18-02988-198 | Pathology Processing Delays at the Memphis VA Medical Center, Tennessee | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures that Memphis VA Medical Center leaders assess staffing needs, to include factors impacting the ability to recruit and retain staff, develop plans to improve staffing and assist in hiring to staff Pathology and Laboratory Medicine Service as required by the Clinical Laboratory Improvement Amendment and Veterans Health Administration.
Closure Date:
2 The Memphis VA Medical Center Director verifies the development and implementation of a formal process to track surgical pathology specimens sent out of the Memphis VA Medical Center for processing and monitors compliance.
Closure Date:
3 The Memphis VA Medical Center Director ensures a comprehensive assessment of the Pathology and Laboratory Medicine Service to identify specific root causes of surgical pathology specimen delays and ensure steps are taken to prevent risk of future occurrences.
Closure Date:
4 The Memphis VA Medical Center Director ensures that Pathology and Laboratory Medicine Service leaders provide an ongoing, comprehensive Quality Management program that identifies the availability of accurate, reliable, and timely test results, and reports to the ordering providers.
Closure Date:
5 The Memphis VA Medical Center Director ensures compliance with required surgical pathology Quality Assurance policies and practices, and that Memphis VA Medical Center leaders monitor compliance.
Closure Date:
6 The Memphis VA Medical Center Director ensures that an ongoing process is developed and implemented for Memphis VA Medical Center oversight of Pathology and Laboratory Medicine Service quality data, that includes documentation of the discussion of quality assurance and analysis of the data and the development of action plans as needed.
Closure Date:
7 The Memphis VA Medical Center Director verifies that all Pathology and Laboratory Medicine Service employees that perform patient testing have updated competencies and documented training on their assigned duties.
Closure Date:
8 The Memphis VA Medical Center Director ensures that Memphis VA Medical Center leaders understand the importance of the issue brief process and comply with the Deputy Under Secretary for Health and Operations Guidance.
Closure Date:
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| 19-07429-195 | Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida | Hotline Healthcare Inspection | ||
1 The West Palm Beach VA Medical Center Director ensures that mental health multidisciplinary treatment plans are completed in accordance with Veterans Health Administration and The Joint Commission guidelines.
Closure Date:
2 The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding the Interdisciplinary Safety Inspection Team and its associated functions.
Closure Date:
3 The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding Mental Health Environment of Care Checklist training prior to entry on unit 3C and annually thereafter.
Closure Date:
4 The West Palm Beach VA Medical Center Director ensures that the Employee Education Service staff assigns Mental Health Environment of Care Checklist on-line training modules to employees according to their duties and assignments.
Closure Date:
5 The West Palm Beach VA Medical Center Director ensures that deficiencies identified during the Mental Health Environment of Care Checklist inspections are abated according to VHA guidelines, and that appropriate risk mitigation strategies are implemented as needed.
Closure Date:
6 The Veterans Integrated Service Network Director ensures that the appropriate Veterans Integrated Service Network level staff complies with guidelines to review semi-annual reports and follow-up to ensure abatement of deficiencies prior to item closure on the Mental Health Environment of Care Checklist.
Closure Date:
7 The Under Secretary for Health takes action to ensure that the Mental Health Environment of Care Checklist Work Group reviews and ranks hazards as submitted through the Patient Safety Assessment Tool, and ensures abatement (or waiver of abatement), as indicated.
Closure Date:
8 The West Palm Beach VA Medical Center Director ensures that patient safety and law enforcement cameras are installed, tested, and monitored according to West Palm Beach VA Medical Center and Veterans Health Administration guidelines.
Closure Date:
9 The West Palm Beach VA Medical Center Director ensures that a policy on 15-minute safety rounding expectations be developed, and that all permanent and temporarily-assigned staff performing 15-minute safety rounding on unit 3C receive appropriate training regarding their duties.
Closure Date:
10 The West Palm Beach VA Medical Center Director develops a mechanism to confirm staff compliance with 15-minute rounding requirements.
Closure Date:
11 The West Palm Beach VA Medical Center Director ensures that managers and leaders with mental health, environment of care, and patient safety-related responsibilities are knowledgeable about areas and policies governing the areas under their purview.
Closure Date:
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| 19-00006-191 | Comprehensive Healthcare Inspection of the Central California VA Health Care System Fresno, California | 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 service chiefs initiate and complete focused professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
3 The chief of staff makes certain that service chiefs include the review of service-specific data for ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
4 The chief of staff ensures service chiefs include review of ongoing professional practice evaluation data in the determination to continue current privileges and monitors the service chiefs’ compliance.
Closure Date:
5 The chief of staff makes certain that the Medical Executive Council meeting minutes consistently reflect the review of focused and ongoing professional practice evaluation results in the decision to recommend continuation of initially granted or ongoing privileges and monitors committee’s compliance.
Closure Date:
6 The associate director ensures that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.
Closure Date:
7 The associate director makes certain that VA police document response time for panic alarm testing at the locked mental health inpatient unit and monitors compliance.
Closure Date:
8 The facility director ensures that electronic access for performing or monitoring controlled substances balance adjustments is limited to appropriate staff and monitors compliance.
Closure Date:
9 The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
Closure Date:
10 The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
Closure Date:
11 The chief of staff ensures that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
Closure Date:
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14957