Date Issued
|
Report Number
22-00879-77
|
Topics: COVID-19
● Financial Management
All Reports
Date Issued
|
Report Number
22-00879-249
|
Topics: COVID-19
● Financial Management
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Office of Management (OM)
Confirm VA has resumed submitting biweekly reports and, therefore, has submitted reports from June 2023 to present as required by the VA Transparency & Trust Act of 2021.
No. 2
to Office of Management (OM)
Confirm that the American Rescue Plan Act of 2021 section 8002 quarterly reports are submitted to Congress within the time frame established on the Consolidated Appropriations Acts of 2022 and 2023, which is no later than 30 days after the end of each fiscal quarter.
No. 3
to Office of Management (OM)
Coordinate with administration and staff office chief financial officers to ensure that the finance office staff responsible for the management of open obligations know and understand VA financial policy requirements for the review of open obligations included in quarterly obligation reports.
Date Issued
|
Report Number
22-00879-93
|
Topics: COVID-19
● Financial Management
Date Issued
|
Report Number
22-00879-196
|
Topics: COVID-19
● Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 4/24/2024
Ensure that Veterans Health Administration fiscal staff are trained on VA financial policy requirements for the preparation and approval of journal vouchers (including expenditure transfers).
Date Issued
|
Report Number
21-03101-73
|
Topics: COVID-19
● Financial Management
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 5/9/2023
Assess the iFAMS configuration to determine whether integration with the payroll subsystems can be accomplished to resolve some of the payroll-related issues that require the need for expenditure transfers.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/5/2024
Establish guidance that outlines the type of documentation required to support the amounts identified in the manual journal vouchers when processing expenditure transfers.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/14/2025
Require medical facility staff have documented authority, through proper delegation, to make purchases.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/1/2025
Verify that medical facility staff segregate duties so that the same person is not both authorizing and receiving goods and services.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/1/2025
Make certain the purchase card holder is not the requestor or approver for the purchase.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/1/2025
Ensure contracting officer’s representatives know and understand their duties and responsibilities for the certification and payment of invoices.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 4/1/2025
Check vendors’ compliance with contract terms to include the comparison of invoiced amounts with the contract line-item unit costs.esponse to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/1/2025
Ensure that medical facility staff track the receipt of goods to make certain they are the correct quantity.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 10/2/2023
Conduct an assessment of lessons learned from the emergency response to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 187,200,000.00
Date Issued
|
Report Number
21-02805-102
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/7/2024
The Under Secretary for Health evaluates provider knowledge and utilization of VA Video Connect technology, including resources such as the Digital Divide Consult, Connected Devices Support Program, and VVC Now and takes action as indicated.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/25/2025
The Under Secretary for Health evaluates availability of clinical and administrative support to providers initiating and completing VA Video Connect encounters and clarifies expectations and requirements to ensure access to virtual care emulates in-person encounters.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/9/2024
The Under Secretary for Health ensures education of providers and support staff regarding VA Video Connect scheduling processes.
Date Issued
|
Report Number
22-02604-74
|
Topics: COVID-19
● Supplies and Equipment
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/11/2023
Document a methodology for determining the number of ventilators required by the Audie L. Murphy Memorial Veterans’ Hospital to fulfill its mission and provide care during routine and emergency operations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/11/2023
Determine whether the remaining ventilators are required to support the hospital’s mission. If excess ventilators are identified, perform procedures to turn them in for reassignment, reutilization, or disposal in accordance with VA Handbook 7002.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,500,000.00
Date Issued
|
Report Number
21-03579-27
|
Topics: COVID-19
Date Issued
|
Report Number
21-03777-218
|
Topics: Appointment Scheduling and Wait Times
● COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/11/2024
Monitor facility follow-up rates by type of care and on a month-over-month basis, establish monitoring metrics, and assist facilities if they fall below these metrics.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/8/2023
Evaluate and update, as appropriate, whether activities that occurred before cancellation and notations of “No Action Other Reason” should be tracked as follow-up.
Date Issued
|
Report Number
22-00879-236
|
Topics: COVID-19
Date Issued
|
Report Number
21-00533-157
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/14/2023
The Under Secretary for Health reviews the processes by which COVID-19 emotional well-being resources were developed and disseminated and takes action as needed to increase and ensure Veterans Integrated Service Network and facility leadership as well as facility staff’s awareness of available resources about the potential risks and signs of burnout.
Date Issued
|
Report Number
21-02125-132
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
Establish a realistic goal for days in storage along with a process for closely monitoring days in storage and taking corrective actions when the goal is not met.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/5/2023
Perform a cost-benefit analysis in conjunction with VA contracting officials and the contractor to determine whether a new process can be implemented that initiates the data plan when a device is issued to the veteran or otherwise reduces unused plan costs.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,336,381.00
Date Issued
|
Report Number
21-03917-123
|
Topics: COVID-19
Date Issued
|
Report Number
21-01724-84
|
Topics: COVID-19
● Community Care
● Care Coordination
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Veterans Integrated Service Network Director confirms that weekly calls with facility and Veterans Integrated Service Network leaders are held to discuss active Improvement Action Plans, progress made, timelines, and next steps.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The Martinsburg VA Medical Center Director verifies that Improvement Action Plans, identifying areas of improvement and outlining recommendations, are in place for unmet national Care in the Community performance metrics.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/18/2023
The Martinsburg VA Medical Center Director confirms that clinical reviews of COVID Priority 1 active consults are completed and documented, monitors compliance, and takes action as warranted.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/21/2022
The Martinsburg VA Medical Center Director ensures a process is in place to review and address consults for patients who died prior to being scheduled or seen by a community care provider to determine if an adverse event occurred as a result of a delay in processing a patient’s consult.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/21/2022
The Martinsburg VA Medical Center Director evaluates the effectiveness of strategies to manage the backlog of active consults and the use of urgent and emergent to prioritize consults for scheduling, determines if changes in practice are warranted, and documents the agreed upon process.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Martinsburg VA Medical Center Director conducts a review to determine who, outside Care in the Community staff, is facilitating appointment scheduling and evaluates if the scheduling assistance of other services is an effective use of resources, and establishes a standardized process to align practices.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/18/2022
The Martinsburg VA Medical Center Director ensures Care in the Community staffing levels are adequate to support the processing of consults according to time frames set by the Veterans Health Administration.
Date Issued
|
Report Number
21-00497-46
|
Topics: COVID-19
● Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/14/2023
Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/21/2023
Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/14/2022
Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.
Date Issued
|
Report Number
21-00913-267
|
Topics: COVID-19
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/12/2022
The OIG recommended the under secretary for health develop processes for verifying facility data entered on the Pharmacy Benefits Management Services’ SharePoint website (or any subsequent data collection tool) for vaccine supply and usage.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health develop a process to monitor the use of tools that have been fielded to standardize data entry for vaccine doses administered by VA medical facilities and clinics to minimize data entry errors, including the Computerized Patient Record System’s clinical reminder, the Occupational Health Record-keeping System 2.0’s guided data entry guidance, and reports that can be used to identify data entry errors in these systems, or in any subsequent systems that VA uses to collect data on vaccinations.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/25/2022
The OIG recommended the under secretary for health make sure that the Power BI dashboard data are reliable, accurate, and complete, and capture all vaccine data more accurately for VA medical facilities in the same healthcare system.
Date Issued
|
Report Number
21-02969-20
|
Topics: COVID-19
Date Issued
|
Report Number
20-03437-26
|
Topics: COVID-19
● Community Care
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/30/2023
The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/12/2023
The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 4/12/2022
The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.
Date Issued
|
Report Number
21-00553-285
|
Topics: COVID-19
● Patient Safety
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Great Lakes Health Care System Director evaluates whether administrative action is warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at the VA Illiana Health Care System, and takes action, as appropriate.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director ensures the plan to monitor and track face mask wearing by staff at the community living center adheres to current Centers for Disease Control and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as warranted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director confirms that all community living center staff identified as requiring respiratory protection are fit tested, trained, and have ready access to respiratory devices.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director ensures a plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding staff with known community exposure to COVID-19, and monitors for compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding community living center residents with known exposure to individuals diagnosed with COVID-19, and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director ensures operability and use of the bed management system for tracking completion of room cleaning.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/12/2022
The VA Illiana Health Care System Director oversees the completion and implementation of a policy for administering aerosol-generating procedures during the COVID-19 pandemic that adheres to Centers for Disease Control and Prevention guidance, and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director evaluates the organizational approach for notifying managers of updated Veterans Health Administration policies and guidance for monitoring actions taken to ensure compliance with new requirements.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/13/2022
The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans Health Administration guidance related to community living center practices, including group activities, disseminated during emergent events such as a pandemic and maintains oversight of community living center leaders’ implementation of such guidance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director directs community living center leaders to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director evaluates the community living center standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure that it provides guidance with specific actions for staff to take when a resident tests positive for COVID-19.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 8/11/2022
The VA Illiana Health Care System Director verifies that COVID-19 testing for community living center residents and staff occurs as required for both routine surveillance and in response to confirmed cases of COVID-19.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 5/13/2022
The VA Illiana Health Care System Director confirms that the community living center COVID-19 standard operating procedure clearly communicates the process, including roles and responsibilities, for notification of a resident’s change in condition or room assignment and communicates the plan to all community living staff.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director executes a process to ensure that the facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the community living center, and when identified, creates a plan to mitigate and manage risk.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 3/8/2022
The VA Illiana Health Care System Director directs those conducting the facility’s after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.
Date Issued
|
Report Number
21-01304-275
|
Topics: COVID-19
● Patient Safety
● Appointment Scheduling and Wait Times
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/16/2022
The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/2/2023
The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/31/2025
The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/16/2022
The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.