Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-04266-115 | Inadequate Oversight of Contracted Disability Exam Cancellations | Review | ||
1 The Under Secretary for Benefits improve the exam management systems to ensure visibility of the information needed to conduct adequate oversight of contracted disability exam cancellations.
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2 The Under Secretary for Benefits ensure staffing is sufficient so that the Medical Disability Examination Program can perform adequate oversight of contracted disability exam cancellations.
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3 The Under Secretary for Benefits take steps to ensure that contracting officer’s representatives with oversight responsibilities for the Medical Disability Examination contracts achieve the VA-required certification level.
Closure Date:
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| 18-03250-130 | Exempt Veterans Charged VA Home Loan Funding Fees | Review | ||
1 Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees during the period from January 1, 2012, through December 31, 2017, and issue refunds.
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2 Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to identify exempt veterans who were charged funding fees prior to January 1, 2012, and issue refunds.
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3 Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to mitigate the lack of real-time funding fee exemption status updates through system enhancements or procedural changes that minimize inappropriate funding fee charges.
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4 Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to conduct periodic reviews to identify exempt veterans charged funding fees from January 1, 2018, forward, and issue refunds in a timely manner.
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5 Under Secretary for Benefits ensures Loan Guaranty Service implements a plan to consistently obtain documentation and verify lenders apply funding fee refunds to veterans’ loan balances in a timely manner.
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| 18-05864-127 | VA’s Compliance with the Improper Payments Elimination and Recovery Act for FY 2018 | Review | ||
1 The Under Secretary for Health implement steps to achieve stated reduction targets for the following programs and activities: Communications, Utilities, and Other Rent; Medical Care Contracts and Agreements; and State Home Per Diem.
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| 18-04669-125 | Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and then monitors the managers’ compliance.
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2 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
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3 The chief of staff ensures that clinical managers clearly define and share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors the clinical managers’ compliance.
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4 The chief of staff ensures providers complete initial evaluations within the required timeframe for all new patients referred for mental health services for military sexual trauma and monitors the providers’ compliance.
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5 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the potential interactions and side effects of newly prescribed medications and monitors the 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 record 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 the committee’s compliance.
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8 The facility director makes certain that the urgent care center is staffed with registered nurses in accordance with VHA policy at all times of operation and monitors compliance.
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9 The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
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| 18-05130-105 | Decision Ready Claims Program Hindered by Ineffective Planning | Audit | ||
1 The Under Secretary for Benefits works with the VA Secretary and Chief Financial Officer to take steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for funds already obligated and expended for medical examinations under the Decision Ready Claims program.
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| 18-00215-83 | Deferrals in the Veterans Benefits Management System | Review | ||
1 The Under Secretary for Benefits implement plans to enhance quality assurance by conducting periodic national oversight of deferrals and ensuring local oversight specifically addresses all aspects of the accuracy of deferrals created in the Veterans Benefits Management System.
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2 The Under Secretary for Benefits establish internal controls documenting Rating Veterans Service Representatives are informed of their mitigated deferrals and corrective action is taken.
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3 The Under Secretary for Benefits update guidance to clarify why certain reason selections should be made for deferrals, provide training on this guidance, and monitor the effectiveness of the training.
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4 The Under Secretary for Benefits establish plans to modify the Veterans Benefits Management System to allow sufficient space for inputting deferral instructions and require claims processors to input references when creating deferrals.
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| 18-02493-122 | Orthopedic Surgery Department and Other Concerns at the Carl T. Hayden VAMC, Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Carl T. Hayden VA Medical Center Director conducts comprehensive reviews of all aspects of decision-making and care provided to Patient Red and Patient Blue, and takes action, as appropriate.
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2 The Carl T. Hayden VA Medical Center Director considers conducting an institutional disclosure in Patient Red’s case, and takes action as appropriate.
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3 The Carl T. Hayden VA Medical Center Director continues efforts to assess and improve inefficiencies, including on-call surgeon accountability issues, within the Orthopedic Surgery Department.
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4 The Carl T. Hayden VA Medical Center Director takes appropriate action relative to the letter of expectation issued to the Chief of Orthopedic Surgery Department.
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5 The Carl T. Hayden VA Medical Center Director addresses inter-departmental communication, collaboration, and problem-solving challenges as discussed in this report.
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6 The Carl T. Hayden VA Medical Center Director follows up on consultative recommendations made by the anesthesia and operating room site visit team.
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7 The Carl T. Hayden VA Medical Center Director evaluates the adequacy of Sterile Processing Services space and the loaner instrument policy, and takes action as appropriate.
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8 The Carl T. Hayden VA Medical Center Director assesses the feasibility of implementing an electronic instrument tracking system within Sterile Processing Services, and takes actions as appropriate.
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9 The Carl T. Hayden VA Medical Center Director revises the orthopedic surgery core privileges description to accurately reflect procedures performed at the Carl T. Hayden VA Medical Center.
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10 The Carl T. Hayden VA Medical Center Director ensures appropriate data collection, analysis, and reporting for orthopedic providers’ ongoing professional practice evaluations.
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11 The Carl T. Hayden VA Medical Center Director develops a physician assistant utilization policy as required by Veterans Health Administration.
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12 The Carl T. Hayden VA Medical Center Director updates physician assistant scopes of practice to fully reflect the activities and listing of surgical first assist responsibilities for individual orthopedic physician assistants.
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| 17-02629-119 | Inpatient Mental Health Clinical Operations Concerns at the Phoenix VA Health Care System, Arizona | Hotline Healthcare Inspection | ||
1 The Phoenix VA Health Care System Director verifies that clinicians document clinical justification for the continued use of restraints and debriefing sessions according to Veterans Health Administration and Phoenix VA Health Care System policy requirements.
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2 The Phoenix VA Health Care System Director makes certain that the Phoenix VA Health Care Patient Safety Observer policy is followed, and compliance is monitored.
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3 The Phoenix VA Health Care System, Director ensures that inpatient mental health unit nurse staffing methodology is conducted as required by Nurse Staffing Methodology for Veterans Health Administration Nursing Personnel Directive.
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4 The Phoenix VA Health Care System, Director confirms that mental health staff receive mandated training at required intervals including training for patients with dementia as appropriate, and compliance is monitored.
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5 The Phoenix VA Health Care System Director verifies that the inpatient mental health unit is cleaned on a regular basis and compliance is monitored.
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6 The Phoenix VA Health Care System Director ensures that the environment on the inpatient mental health unit is a home-like therapeutic setting as required by Veterans Health Administration Inpatient Mental Health Services Handbook.
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7 The Phoenix VA Health Care System Director ensures that Phoenix VA Health Care System staff enter complaints into the Patient Advocate Tracking System consistent with current Veterans Health Administration Patient Advocacy Program and facility policies and compliance is monitored.
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| 17-02186-114 | Staffing, Quality of Care, Supplies, and Care Coordination Concerns at the VA Loma Linda Healthcare System, California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Healthcare System Director defines goals, implements measures, and monitors outcomes to improve the flow of patients throughout the hospital, including the Emergency Department, inpatient medical and surgical units, mental health units, and the Community Living Center.
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2 The VA Loma Linda Healthcare System Director conducts a review to evaluate the accuracy of data entered in Emergency Department Integration Software and takes action to ensure that the data collection tool may be used for operational improvement.
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3 The VA Loma Linda Healthcare System Director ensures that patients admitted to a unit where there is no bed available receive the same level of care that is provided in the unit to which they are assigned.
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4 The VA Loma Linda Healthcare System Director ensures that bed closures are reported to the Veterans Integrated Service Network as required by VA Loma Linda Healthcare System policy.
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5 The VA Loma Linda Healthcare System Director evaluates the care of patients with sepsis in the Emergency Department, identifies opportunities for improvement, and takes actions to improve care.
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6 The VA Loma Linda Healthcare System Director evaluates the response time of psychiatrists consulted for the care of mental health patients in the Emergency Department and takes action if required.
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7 The VA Loma Linda Healthcare System Director conducts an evaluation of Patient C’s 2016 coordination of care, discharge planning, and transfer of care, including but not limited to, conferring with the Director of the Robley Rex Veterans Affairs Medical Center, Louisville, Kentucky, and takes action as necessary.
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8 The VA Loma Linda Healthcare System evaluates, develops, and implements processes for veterans who have anticipated or unexpected medical needs coordinated by their preferred medical facility and an alternate medical facility.
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9 The VA Loma Linda Healthcare System Director evaluates and ensures that root cause analyses are completed in accordance with Veterans Health Administration directives.
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10 The VA Loma Linda Healthcare System Director reviews the care of the two fall patients with injuries discussed in this report, adheres to Veterans Health Administration policies, and takes action as appropriate.
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| 18-03159-74 | Improper Coding and Unnecessary Overtime at the Central Texas Veterans Health Care System | Audit | ||
1 The Central Texas Veterans Health Care System Director ensures all psychologists are properly trained on coding.
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2 The Central Texas Veterans Health Care System Director instructs the Chief of Psychology to review care provider coding accuracy in routine evaluations.
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3 The Central Texas Veterans Health Care System Director makes certain the Chief of Health Information Management performs annual reviews of provider coding as specified in VHA policy.
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4 The Central Texas Veterans Health Care System Director confirms that the Chief and Assistant Chief of Medical Administration Service, along with the Compliance Officer, provide adequate oversight of the Health Information Management provider coding reviews.
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5 The Central Texas Veterans Health Care System Director ensures clinic hours are sufficiently scheduled to maximize direct patient care and to achieve targeted productivity.
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6 The Central Texas Veterans Health Care System Director makes certain that all telehealth clinics follow VHA’s scheduling policies by using the approved electronic scheduling system and assigns properly trained telehealth schedulers.
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7 The Central Texas Veterans Health Care System Director oversees proper disposal of the paper planner and secures patient information.
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8 The Central Texas Veterans Health Care System Director makes certain the Chief of Psychology determines, before authorizing overtime, whether the requested services could be performed during normal working hours.
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14957