Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-04658-250 | Leasing Procedures Used to Acquire VA’s Wilmington Health Care Center | Audit | ||
1 The OIG recommended the Executive Director for Construction and Facilities Management establish and disseminate a formal policy for transferring contract files when transferring responsibilities to a different contracting officer.
Closure Date:
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| 18-01139-267 | Comprehensive Healthcare Inspection Program Review of the Battle Creek VA Medical Center, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that clinical managers initiate and complete Focused Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
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| 17-04569-262 | Inpatient Security, Safety, and Patient Care Concerns at the Chillicothe VA Medical Center, Ohio | Hotline Healthcare Inspection | ||
1 The Chillicothe VA Medical Center Director ensures that the windows of patient care areas remain secure in accordance with Veterans Health Administration Center for Engineering and Occupational Safety and Health guidelines.
Closure Date:
2 The Chillicothe VA Medical Center Director makes certain that the Chillicothe VA Medical Center’s policy for Special Observation is followed and monitors for compliance.
Closure Date:
3 The Chillicothe VA Medical Center Director verifies that training and staff competencies are completed for Prevention and Management of Disruptive Behavior and Special Observation as required.
Closure Date:
4 The Chillicothe VA Medical Center Director confers with the Office of Chief Counsel regarding the notification of the patient’s death and discussion of institutional disclosure with the next-of-kin and takes action as appropriate.
Closure Date:
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| 17-01823-287 | Illicit Fentanyl Use and Urine Drug Screening Practices in a Domiciliary Residential Rehabilitation Treatment Program at the Bath VA Medical Center, New York | Hotline Healthcare Inspection | ||
1 The Veterans Health Administration Under Secretary for Health ensures that drug screening guidelines for VA facilities are reviewed to determine if fentanyl should be included in routine urine drug screening, and takes appropriate action.
Closure Date:
2 The Veterans Health Administration Office of Mental Health Services, Substance Use Disorders, Director considers developing and implementing a monitoring program to identify regional trends of drug abuse for facilities.
Closure Date:
3 The Veterans Integrated Service Network 2 Director evaluates laboratory processes for fentanyl test results and takes appropriate action to ensure timely turnaround times and notification of results.
Closure Date:
4 The Bath VA Medical Center Director ensures accurate tracking and monitoring of positive urine drug screening data.
Closure Date:
5 The Bath VA Medical Center Director ensures that all Domiciliary Residential Rehabilitation Treatment Program clinical staff are trained on the interpretation of urine drug screening laboratory results.
Closure Date:
6 The Bath VA Medical Center Director consults with appropriate personnel including ethics, legal counsel, privacy office, suicide prevention, and relevant Veterans Health Administration Program Office Directors to evaluate the risk identification/color-coded sticker system and ensure the practice is consistent with privacy standards and best practices.
Closure Date:
7 The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided personal protective equipment for use while conducting searches of resident belongings and rooms.
Closure Date:
8 The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided training on conducting safe and effective searches of resident rooms and belongings.
Closure Date:
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| 18-00608-247 | Comprehensive Healthcare Inspection Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that an interdisciplinary facility group reviews utilization management data and monitors compliance.
Closure Date:
2 The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to Facility leaders at the completion of each fiscal year and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that Executive Committee of the Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion in order to recommend approval of clinical privileges for licensed independent practitioners and monitors compliance.
Closure Date:
4 The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired licensed independent practitioners and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months and monitors compliance.
Closure Date:
6 The Associate Director ensures required team member participate in environment of care rounds and monitors compliance.
Closure Date:
7 The Associate Director ensures sterilized surgical instruments in the podiatry clinic are appropriately labeled with expiration dates or statements and monitors compliance.
Closure Date:
8 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
9 The Facility Director ensures that the Alternate Controlled Substance Coordinator’s position description or functional statement includes an addendum for the Controlled Substance Coordinator’s duties and monitors compliance.
Closure Date:
10 The Facility Director ensures that monthly controlled substance inspections are completed in all required areas and monitors compliance.
Closure Date:
11 The Facility Director ensures that all controlled substance inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
Closure Date:
12 The Facility Director ensures that required pharmacy inspections are completed monthly and monitors compliance.
Closure Date:
13 The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive Posttraumatic Stress Disorder screens and monitors compliance.
Closure Date:
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| 16-04558-249 | VA Policy for Administering Traumatic Brain Injury Examinations | Audit | ||
1 The Under Secretary for Benefits coordinate with the Under Secretary for Health to determine whether veterans who had received initial TBI medical examinations by VHA-contracted examiners and not by one of the four designated specialists, were unintentionally excluded from equitable relief. If additional veterans are identified, the OIG requests that those cases be referred to the VA Secretary for consideration of equitable relief.
Closure Date:
2 The Under Secretary for Benefits confirm whether the names of veterans who were not on the initial list of veterans entitled to equitable relief and later identified by VBA staff and referred for potential equitable relief were submitted to the VA Secretary for consideration. The OIG requests an update of the current status and disposition of those cases.
Closure Date:
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| 16-02103-265 | Review of Accuracy of Reported Pending Disability Claims Backlog Statistics | Review | ||
1 The OIG recommended the Under Secretary for Benefits consider revising which claims are included in VBA’s reported disability claims backlog and provide a clear definition to all stakeholders.
Closure Date:
2 The OIG recommended the Under Secretary for Benefits implement a plan to provide consistent oversight and training of Claims Assistants through national performance and training plans.
Closure Date:
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| 17-02713-231 | Bulk Payments Made under Patient-Centered Community Care/Veterans Choice Program Contracts | Audit | ||
1 The Executive in Charge, Office of the Under Secretary for Health, continue to support processes to prevent duplicate payments made to third-party administrators through the bulk payment process and ensure that proper controls are in place to prevent duplicate payments to third-party administrators through all other current payment methodologies and under future Community Care contracts.
Closure Date:
2 The Executive in Charge, Office of Under Secretary for Health, ensure that Office of Community Care staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant government authorities to review and determine an appropriate process for reimbursement of overpayments by the third-party administrators.
Closure Date:
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| 18-01013-263 | Comprehensive Healthcare Inspection Program Review of the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
Closure Date:
2 The Associate Director ensures the VA Police regularly test panic alarms at the Hot Springs community based outpatient clinic and monitors compliance.
Closure Date:
3 The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing at the locked mental health unit and monitors compliance.
Closure Date:
4 The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.
Closure Date:
5 The Facility Director ensures that reconciliation of controlled substances dispensing from the pharmacy to every automated dispensing cabinet and returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
Closure Date:
6 The Facility Director ensures that controlled substances inspectors verify written controlled substance orders during monthly area inspections and monitors compliance.
Closure Date:
7 The Facility Director ensures controlled substances inspectors complete emergency drug cache inspections and monitors compliance.
Closure Date:
8 The Chief of Staff ensures providers complete suicide risk assessments within the required timeframe for patients with positive post-traumatic stress disorder screens and monitors compliance.
Closure Date:
9 The Facility Director ensures that the Joint Leadership Council maintain oversight of all geriatric evaluation program performance improvement activities and monitors compliance.
Closure Date:
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| 17-05244-226 | Accuracy of Effective Dates for Reduced Evaluations Needs Improvement | Audit | ||
1 The Under Secretary for Veterans Benefits Administration implement a plan to ensure staff timely process cases with reduced evaluations, after the decision, to prevent rework and improper payments.
Closure Date:
2 The Under Secretary for Veterans Benefits Administration establish a plan to modify the Veterans Benefits Management System to apply correct effective dates for cases with reduced evaluations for conditions that were no longer service-connected and alert staff when the assigned effective dates are improper.
Closure Date:
3 The Under Secretary for Veterans Benefits Administration remind VA Regional Office staff of the system defect that causes effective dates to be one month later than required for conditions that are no longer being classified as service-connected, until the Veterans Benefits Administration could implement a system change.
Closure Date:
4 The Under Secretary for Veterans Benefits Administration implement a plan to provide refresher training on the proper processing of reduced evaluations to staff who process rating reductions and monitor the effectiveness of that training.
Closure Date:
5 The Under Secretary for Veterans Benefits Administration provide updated guidance to include provisions for when amended proposal letters are necessary.
Closure Date:
6 The Under Secretary for Veterans Benefits Administration implement a plan to conduct periodic reviews for veterans who had evaluations reduced after the first of the month following the final notification letter and before the first of the month following 60 days after the final notification letter, take corrective actions as needed, and provide certification of completion to the Office of Inspector General.
Closure Date:
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14957