Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-02830-164 | State Prescription Drug Monitoring Programs Need Increased Use and Oversight | Audit | ||
1 Develop national processes to oversee medical facility compliance with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, and coordinate the possible automated information technology solutions and inter-office and -disciplinary communications necessary to improve prescription drug monitoring program monitoring and usage in Veterans Health Administration.
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2 Update the Pain Management and Opioid Safety training course to specifically address VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, query requirements and recommendations.
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3 Ensure VA clinicians who prescribe opioids take the Pain Management and Opioid Safety training once, with annual refresher training.
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4 Add an addendum to VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, that references the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain and ensure VA clinicians are educated and receive annual training on the Clinical Practice Guideline, to include the Centers for Disease Control and Prevention’s recommended frequency for prescription drug monitoring program queries based on the patients’ risk factors.
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5 Direct Veterans Integrated Service Networks and their VA medical facilities to ensure local policies are consistent with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs.
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6 Develop automated information technology solutions to facilitate clinicians’ access toprescription drug monitoring program query information and reinforce the need tocomplete minimum annual VA-required prescription drug monitoring program queries.
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7 Ensure non-VA care clinicians are in good standing and have a current state medical license that requires adherence to their state’s prescription drug monitoring program query requirements; adhere to the Veterans Affairs Opioid Safety Initiative Guidelines, including guidelines for prescription drug monitoring program queries; and are monitored to ensure appropriate corrective actions are taken if their prescribing practices are found to be inconsistent with VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
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8 Ensure Veterans Integrated Service Networks implement an effective prescription drug monitoring program oversight process that includes the review of compliance rates with medical facility directors.
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| 18-03526-230 | Alleged Care Delays and Inadequate Instrument Precleaning at the New Mexico VA Health Care System, Albuquerque | Hotline Healthcare Inspection | ||
1 The New Mexico VA Health Care System Director ensures that patients denied a Veterans Choice Program referral are informed of their rights to appeal, that facility policy is consistent with Veterans Health Administration requirements, and monitors compliance.
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2 The New Mexico VA Health Care System Director verifies that the Ophthalmology and Optometry Departments’ consult management and scheduling practices are consistent with Veterans Health Administration patient indicated date timeframe requirements, incorporates patient preference, and includes receiving provider review of consults, and monitors compliance.
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3 The New Mexico VA Health Care System Director makes certain the Ophthalmology and Optometry Departments’ clinical and administrative staff receive training regarding Veterans Health Administration requirements of consult management and scheduling practices.
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4 The New Mexico VA Health Care System Director reviews the Ophthalmology Department’s eye cataract intake surgery scheduling practice and ensures that overall timeliness is consistent with Veterans Health Administration directives, and monitors compliance.
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5 The New Mexico VA Health Care System Director conducts a timeliness review of the authorization process for non-VA Care routine eye appointments, including diabetic eye examinations, and implement action plans if the process fails to adhere to Veterans Health Administration directives.
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6 The New Mexico VA Health Care System Director ensures the Gastroenterology Department’s consult management practices are consistent with Veterans Health Administration scheduling requirements for patient indicated dates, and monitors compliance.
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7 The New Mexico VA Health Care System Director establishes a routine review of Gastroenterology Department consult performance measures and a method to monitor identified deficiencies consistent with Veterans Health Administration requirements.
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8 The New Mexico VA Health Care System Director evaluates whether test results within the past 12 months, ordered by the Gastroenterology Department were communicated to patients according to Veterans Healthcare Administration and facility policy, and takes action as necessary based on the results of the evaluation.
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9 The New Mexico VA Health Care System Director reviews facility policy for the ordering and reporting of test results to be in alignment with Veterans Health Administration directives and completes revisions, if needed.
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10 The New Mexico VA Health Care System Director ensures that Gastroenterology Department-ordered test results are communicated timely in accordance with Veterans Health Administration and facility policy and the timeliness is monitored through the ongoing peer review process as required by facility policy.
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11 The New Mexico VA Health Care System Director ensures that the Gastroenterology Department Service Chief develop a process for delegating responsibility and accountability for test results and follow-up when multiple providers are involved, and monitors compliance.
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12 The New Mexico VA Health Care System Director ensures documented endoscope precleaning training for Gastroenterology Fellows, and monitors compliance.
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13 The New Mexico VA Health Care System Director verifies that documentation of endoscope precleaning competencies for Gastroenterology Fellows is consistent with Veterans Health Administration requirements.
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| 19-07350-192 | Boston, Massachusetts, VA Regional Office Supervisor Incorrectly Processed Work Items | Review | ||
1 The director of the Boston VA Regional Office reviews and corrects all work items that were cancelled or cleared by the supervisor that are likely to result in adjustments to recipients’ benefit payments.
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2 The director of the Boston VA Regional Office confers with regional counsel to determine the appropriate administrative action to take, if any, against the supervisor.
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3 The director of the Boston VA Regional Office implements a plan to ensure internal controls for assessing the quality of claims processed by supervisors.
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| 18-00777-224 | Quality of Care and Patient Safety Concerns on the Acute Behavioral Health Unit at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania | Hotline Healthcare Inspection | ||
1 The Corporal Michael J. Crescenz VA Medical Center Director ensures that providers understand the importance of monitoring for cardiac changes, drug-drug interactions, and signs of oversedation when initiating patients on methadone.
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2 The Corporal Michael J. Crescenz VA Medical Center Director monitors that providers and clinical staff effectively and directly communicate with one another when providing complex patient care.
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3 The Corporal Michael J. Crescenz VA Medical Center Director confirms that the issue brief submitted on the identified patient contains accurate information.
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4 The Corporal Michael J. Crescenz VA Medical Center Director reviews the root cause analysis related to the identified patient to determine if the team composition compromised the integrity of the root cause analysis and take appropriate action if necessary.
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5 The Corporal Michael J. Crescenz VA Medical Center Director ensures that root cause analysis team compositions include appropriate staff and monitor compliance.
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6 The Corporal Michael J. Crescenz VA Medical Center Director considers Peer Review for Quality Management for the additional two providers identified in this report.
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7 The Corporal Michael J. Crescenz VA Medical Center Director ensures that Unit 7E staff are knowledgeable of the observation policy, and nursing leaders are monitoring staff compliance when assigned rounding responsibilities.
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8 The Corporal Michael J. Crescenz VA Medical Center Director completes actions initiated or taken to resolve identified deficiencies that contributed to the events discussed in this report, and monitors for compliance.
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9 The Corporal Michael J. Crescenz VA Medical Center Director certifies that providers receive ongoing education on the required elements of a signed written consent prior to the initiation of methadone and ensures that providers comply with VA policy and monitors for compliance.
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| 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,
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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2 Develop a plan to update the rating schedule to establish more objective criteria for each level of evaluation for peripheral nerves.
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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.
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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.
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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.
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15039