Date Issued
|
Report Number
17-03557-19
All Reports
Date Issued
|
Report Number
14-02890-378
Date Issued
|
Report Number
17-01208-07
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires staff to immediately verify resuscitation status without delaying resuscitative efforts.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/29/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers update the Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation policies to align with one another and include specific processes and responsibilities for determining resuscitation status, including at the time of a Nurse Led Rapid Response.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers educate staff on telemetry policy, align clinical practice with policy, educate staff on this policy and practice, and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers obtain an independent external review of this patient’s medical care.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/6/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director consider taking appropriate administrative action for all involved clinicians, including consideration of the reporting requirements to applicable state licensing board(s).
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/21/2018
We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers review electronic health record documentation of resident supervision, medical decision-making, and resident physician to attending physician discussion of care during an emergency situation and monitor compliance.
Date Issued
|
Report Number
16-00352-12
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that System leaders establish written protocols to identify a process to transfer Emergency Department boarded patients to available VA and non-VA facilities when acute inpatient beds are unavailable.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that the policy that designates the location for Emergency Department patient overflow includes criteria for boarded patients who can be placed in the community living center.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that a policy is developed and implemented to ensure that Emergency Department staff offer boarded patients transfer to a VA or non-VA facility for inpatient care and that Emergency Department staff document the offers and managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director ensure that managers continue to strengthen processes to improve boarded patients’ length of stay in the Emergency Department.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/30/2018
We recommended that the Veterans Integrated Service Network Director ensure that Emergency Department providers reassess patients prior to transfer to confirm that patients are stabilized and suitable for transfer to the receiving unit.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director implement applicable recommendations from previous patient event-related reviews and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director consult with the Office of Chief Counsel regarding whether an institutional disclosure might be appropriate.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the Veterans Integrated Service Network Director consider requesting an external administrative review to determine whether the system was adequately prepared to safely manage its patient volume.
Date Issued
|
Report Number
16-02676-13
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the Veterans Integrated Service Network Director review the former Chief of Surgery’s performance in relation to issues discussed in this report, and confer with appropriate VA offices to determine the need for administrative action, if any.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended the System Director consult with the National Center for Organizational Development to facilitate organizational improvement following leadership changes and extensive inspections and investigations.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure use of the correct methodology to determine the severity assessment code for all reported patient safety events.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure compliance with the National Center for Patient Safety’s guidelines on initiation and completion of Root Cause Analysis.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure that peer reviews are appropriately completed and address all relevant aspects of care provided by the reviewed clinician.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure a process is in place to identify and review cases where institutional disclosure may be indicated, and complete as appropriate.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended the System Director ensure that the Quality, Safety and Value committee minutes include evidence of robust data analysis and action tracking to address performance deficiencies, and monitor for compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure adherence to all Veterans Health Administration peer review committee requirements, and monitor for compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure that professional practice evaluations include performance data to support provider privileges and are conducted in accordance with Veterans Health Administration and System policy.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director evaluate the current System policy and services provided by low volume/no volume providers to determine whether the System should continue to provide those services or seek community alternatives.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director require service chiefs to assure that all providers within their purview secure and maintain appropriate computer access to ensure quality and continuity of patient care.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 6/12/2018
We recommended that the System Director ensure availability of functional equipment, adequate staffing, and enhanced access for personal identity verification card completion.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director ensure compliance in monitoring of resident supervision documentation in accordance with Veterans Health Administration and System policies, and take appropriate action when deficiencies are identified.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director review letters of agreement between the University of Oklahoma’s surgical residency program and the System to ensure compliance with Accreditation Council for Graduate Medical Education requirements.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director continue efforts to recruit and hire for vacancies, and ensure that, until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director ensure timely completion of specialty care consults and monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 4/25/2018
We recommended that the System Director implement a process to conduct routine scheduling audits to monitor compliance and identify ongoing training opportunities for all schedulers.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director conduct an evaluation of the potential improper payments resulting from clinic cancellations, take appropriate corrective actions, and establish policies to mitigate improper payments related to clinic cancellations from occurring in the future.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director continue efforts to improve call center timeliness.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director continue efforts to improve timeliness of Care in the Community Program consult completion; enhance patient and community provider understanding of Veterans Choice and Non-VA Care Coordination options; and continue to promote communication and coordination with TriWest Healthcare Alliance to assure appropriate, timely care for patients.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director ensure Patient Aligned Care Team clinicians follow Veteran Health Administration requirements for patient notification and follow-up of clinically relevant abnormal laboratory results and document the actions in the electronic health record.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 11/2/2017
We recommended that the System Director monitor consultation completion timeliness and identify process improvements for consults exceeding 30 days.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director continue Emergency Department workgroup efforts to improve the timeliness of care, decrease the frequency of diversion status, and enhance customer service in the Emergency Department.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 10/17/2018
We recommended that the System Director ensure that all patient care areas comply with environment of care requirements and that action plans specifically address deficient areas identified in this report.
Date Issued
|
Report Number
15-04156-352
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 11/1/2017
We recommended the Acting Under Secretary for Benefits clarify the guidance for VA general medical examinations requirements related to original pension claims.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 5/30/2018
We recommended the Acting Under Secretary for Benefits ensure staff at the Pension Management Centers receive training based on the clarified guidance for VA medical general examination requirements related to original pension claims.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/21/2018
We recommended the Acting Under Secretary for Benefits ensure St. Paul claims processing staff review the 605 pension claims denied without a VA general medical examination in CY 2015 to determine whether corrective action is necessary based on clarified guidance and report to the OIG the number of denials reversed.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 4/3/2018
We recommended the Acting Under Secretary for Benefits develop and implement a plan to ensure rating consistency across Pension Management Centers.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 11/1/2017
We recommended the Acting Under Secretary for Benefits implement a plan to ensure claims processing staff prioritize actions for cases involving benefits reductions based on Medicaid-covered nursing home care to minimize improper payments.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 9/21/2018
We recommended the Acting Under Secretary for Benefits develop workload performance measures for cases involving benefits reductions based on Medicaid-covered nursing home care to minimize improper payments.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 5/30/2018
We recommended the Acting Under Secretary for Benefits develop and implement training for claims processing staff that is specific to Medicaid-covered nursing home cases.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 41,400,000.00
Date Issued
|
Report Number
16-03922-392
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2018
We recommended the Acting Under Secretary for Benefits ensure National Pension Call Center management implements controls to require supervisors to review and take corrective actions for inaccuracies identified when evaluating calls.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 6/6/2019
We recommended the Acting Under Secretary for Benefits ensure Benefits Assistance Service has qualified staff to evaluate the quality of Spanish-speaking calls received at the National Pension Call Center.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2018
We recommended the Acting Under Secretary for Benefits ensure National Pension Call Center and Benefits Assistance Service management implement controls to help ensure staff complies with all training requirements identified in Benefits Assistance Service National Training Curriculum.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 3/29/2018
We recommended the Acting Under Secretary for Benefits ensure National Pension Call Center management implements controls to ensure staff completes course evaluations or assessments for instructor-led training in the Talent Management System to record training hours timely.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 6/13/2018
We recommended the Acting Under Secretary for Benefits continuously evaluate the NPCC Cisco data and determine if a plan is needed to modify operating hours to accommodate callers, including those residing outside the Eastern Time Zone.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 1/15/2019
We recommended the Philadelphia VA Regional Director strengthen controls at Philadelphia VA regional office to help ensure correspondence that may include personally identifiable information is mailed to the intended veteran.
Date Issued
|
Report Number
15-05519-377
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/24/2018
We recommended the Veterans Integrated Service Network 15 Director submit ratification requests for the fiscal year 2015 unauthorized commitments identified in our report to the Veterans Health Administration’s Head of Contracting Activity.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/19/2018
We recommended the Veterans Integrated Service Network 15 Director, in coordination with the Network Contracting Office Director, conduct additional focused training for its purchase cardholders and approving officials on what constitutes splitting purchases and how to avoid them.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
We recommended the Veterans Integrated Service Network 15 Director, in coordination with the Network Contracting Office Director, establish more rigorous monitoring mechanisms to identify improper purchase card transactions.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 73,000.00
Date Issued
|
Report Number
16-01091-06
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/22/2018
We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program counselors provide treatment planning consistent with Title 42 of the Code of Federal Regulations Part 8, Substance Abuse and Mental Health Services Administration guidelines, and local policy requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program counselors provide counseling sessions consistent with Title 42 of the Code of Federal Regulations Part 8, Substance Abuse and Mental Health Services Administration guidelines, and local policy requirements.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure that Baltimore VA Medical Center Opioid Agonist Treatment Program leaders consider implementing clear policies regarding the management of cardiac risk that include annual electrocardiographic assessment consistent with Substance Abuse and Mental Health Services Administration guidelines.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure Opioid Agonist Treatment Program administrative policies assign regulatory compliance responsibilities consistent with Title 42 of the Code of Federal Regulations Part 8 and Substance Abuse and Mental Health Services Administration guidelines.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/21/2018
We recommended that the VA Maryland Health Care System Director ensure that the Baltimore VA Medical Center Opioid Agonist Treatment Program Medical Director is present at the program a sufficient number of hours to ensure regulatory compliance consistent with Title 42 of the Code of Federal Regulations Part 8 and Substance Abuse and Mental Health Services Administration guidelines.
Date Issued
|
Report Number
17-02084-343
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2017
We recommended the Anchorage VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due
process time period.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Anchorage VA Regional Office Director
strengthen oversight to ensure data input at the time of claims
establishment is reviewed for accuracy.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2017
We recommended the Anchorage VA Regional Office Director
implement a plan to monitor the effectiveness of training related to claims establishment procedures.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Anchorage VA Regional Office Director provide training for designated congressional liaison staff who process special controlled correspondence and monitor the effectiveness of the training.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 2/12/2018
We recommended the Anchorage VA Regional Office Director
implement a plan to ensure oversight is strengthened for special
controlled correspondence.
Date Issued
|
Report Number
16-00753-338
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended the Veterans Integrated Service Network 23 Director consult with VA’s Office of General Counsel and take necessary corrective actions to correct the funding error related to the purchase of WiFi and cable television services and ensure that appropriate funds are used for future information technology purchases in accordance with VA policy and VA’s Office of General Counsel guidance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended the Veterans Integrated Service Network 23 Director work with the Chief Financial Officer to determine if an Antideficiency Act violation occurred and take action as deemed appropriate.
No. 3
to Information and Technology (OIT)
Closure Date: 2/5/2018
We recommended the Acting Assistant Secretary for Information and Technology update the 2016 IT/Non-IT Policy to address the dissemination of decisions and issues that may be systemic across VA.
Date Issued
|
Report Number
16-04991-387
Date Issued
|
Report Number
16-00838-348
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 9/29/2017
We recommended the Acting Assistant Secretary for Information and Technology implement appropriate controls to ensure that Class III software is not installed on VA networks without a formal technical review and authority to operate, and that training is provided to OIT Region 1 staff on the treatment of Class III software.
Date Issued
|
Report Number
16-00546-388
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility ensure the designated quality, safety, and value committee meets quarterly and is chaired or co-chaired by the Facility Director.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility revise the policy/by-laws to specify a frequency for clinical managers to review practitioners’ Ongoing Professional Practice Evaluation data every 6 months.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/11/2019
We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that the facility consistently evaluate actions for effectiveness in the Clinical Executive Committee and Performance Improvement Board and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that facility managers ensure all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/3/2018
We recommended that facility managers ensure horizontal surfaces, ventilation grills, and floors in patient care areas are clean and monitor compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that facility managers ensure ice machines and refrigerators in patient nourishment kitchens are clean and monitor compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that facility managers ensure the standard operating procedure for the retrograde cholangiopancreatography endoscope is consistent with the manufacturer’s instructions for use.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive competencies at orientation and annually for the types of reusable medical equipment they reprocess.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility revise the policy for anticoagulation management to include addressing no shows and patient noncompliance and minimizing loss to follow-up.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that clinical managers complete semiannual competency assessments for employees actively involved in the anticoagulant program and that facility managers monitor compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 6/13/2018
We recommended that the facility collect and report data on patient transfers out of the facility.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 11/18/2019
We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in transfer documentation and that facility managers monitor compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
We recommended that facility managers ensure that for emergent transfers, provider transfer notes include patient stability for transfer and monitor compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 5/10/2019
We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 8/20/2019
We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
No. 20
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
We recommended that the facility report and trend the use of reversal agents in moderate sedation cases and process adverse events/complications in a similar manner as operating room anesthesia adverse events and that facility managers monitor compliance.
No. 21
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the VA Police Officer, Patient Safety Manager and/or Risk Manager, and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
No. 22
to Veterans Health Administration (VHA)
Closure Date: 8/14/2018
We recommended that the facility collect and analyze data from disruptive or violent behavior incidents.
No. 23
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
No. 24
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
No. 25
to Veterans Health Administration (VHA)
Closure Date: 5/19/2020
We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
No. 26
to Veterans Health Administration (VHA)
Closure Date: 6/14/2018
We recommended that all doors on the Domiciliary Care for Homeless Veterans Program unit other than the main point of entry be locked and alarmed.
No. 27
to Veterans Health Administration (VHA)
Closure Date: 2/16/2018
We recommended that the facility fully implement the nurse staffing methodology and conduct annual reassessments.
Date Issued
|
Report Number
15-04929-351
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/1/2018
We recommended the Acting Under Secretary for Health require Prosthetic and Sensory Aids Service conduct periodic analyses of Veterans Health Administration prosthetic purchases to identify commonly used prosthetics that offer opportunities for VA’s Strategic Acquisition Center to leverage Veterans Health Administration’s purchasing power by pursuing Veterans Health Administration-wide or multi-Veterans Integrated Service Network contracts.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/24/2018
We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office and Prosthetics and Sensory Aids Service to periodically monitor prosthetic procurements to ensure Veterans Integrated Service Networks and Network Contracting Offices identify and report prosthetics usage and cost data for use in developing Veterans Integrated Service Network contracts when Veterans Health Administration wide or multi-Veterans Integrated Service Network contracts are not possible.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/8/2018
We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office to review fiscal years 2015 and 2016 prosthetic purchase card transactions above the micro-purchase limit and submit identified unauthorized commitments to Heads of Contracting Activities for ratification actions.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/8/2018
We recommended the Acting Under Secretary for Health direct Heads of Contracting Activities to perform ratification actions for unauthorized commitments identified by the Procurement & Logistics Office review of fiscal years 2015 and 2016 prosthetic purchase card transactions above the micro-purchase limit and consider holding cardholders and their approving officials accountable for unauthorized commitments, as appropriate.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/24/2018
We recommended the Acting Under Secretary for Health require the Procurement and Logistics Office to develop a process for conducting periodic reviews to evaluate compliance with the requirements of VHA Directive 1081, VA Procurement Policy Memorandum 2016-02, and the Veterans Health Administration’s Memorandum, Implementation of the Implant Pre-authorization Process.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,120,699,904.00
Date Issued
|
Report Number
16-02151-320
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/3/2018
We recommended the director of the STVHCS instruct PRMC to stop advising veterans that they may be liable for pre-authorized NVC.
Date Issued
|
Report Number
17-00266-349
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 2/6/2018
We recommended the Winston-Salem Regional Office Director develop and implement a plan to monitor the effectiveness of training on higher-level special monthly compensation and ancillary benefits claims at the Winston-Salem VA Regional Office.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/6/2018
We recommended the Winston-Salem VARO Director develop and implement a plan to ensure secondary reviewers accurately evaluate higher-level special monthly compensation and ancillary benefits claims at the Winston-Salem VA Regional Office.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/6/2018
We recommended the North Atlantic District Director implement a plan to ensure oversight and prioritization of proposed rating reduction cases at the Winston-Salem VA Regional Office.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 2/6/2018
We recommended that the Winston-Salem VARO Director ensure management provides a consistent quality review process addressing all elements required when establishing claims in the electronic record.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 5/2/2018
We recommended the Winston-Salem VA Regional Office Director ensure VSC staff receive all mandatory annual training on claims establishment procedures.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/6/2018
We recommended the Winston-Salem VA Regional Office Director implement a plan to ensure the Public Contact Coach and Congressional Liaisons adhere to Veterans Benefits Administration policy when processing special controlled correspondence.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 2/6/2018
We recommended the Winston-Salem VA Regional Office Director provide standardized training to Congressional Liaisons on processing special controlled correspondence.
Date Issued
|
Report Number
15-01415-382
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/3/2018
We recommended that the System Director ensure that providers document clinical judgement, coordination of care, communication with the patient or referring facility, and an accurate plan of care from initial assessment to procedure for transcatheter aortic valve replacement patients.
Date Issued
|
Report Number
17-00936-385
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
We recommended that the Acting Under Secretary for Health ensure that the Veterans Health Administration implements staffing models for critical need occupations.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/2/2018
We recommended that the Acting Under Secretary for Health review the Veterans Health Administration report on regrettable losses and implement effective measures to reduce such losses.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/19/2020
We recommended that the Acting Under Secretary for Health continue incorporating data that predict changes in veteran demand for health care into its staffing model.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 11/5/2019
We recommended that the Acting Under Secretary for Health continue assessing the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.
Date Issued
|
Report Number
16-02241-375
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/11/2019
We recommended that the System Director ensure that primary care appointment scheduling processes are assessed and action is taken to ensure timely access for new and established patients.