Date Issued
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Report Number
14-02890-173
All Reports
Date Issued
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Report Number
14-02890-157
Date Issued
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Report Number
14-03128-158
Date Issued
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Report Number
14-02890-127
Date Issued
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Report Number
14-02890-125
Date Issued
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Report Number
14-02890-122
Date Issued
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Report Number
14-02890-154
Date Issued
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Report Number
14-02890-120
Date Issued
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Report Number
14-02890-134
Date Issued
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Report Number
14-02890-124
Date Issued
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Report Number
14-02890-136
Date Issued
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Report Number
14-03403-128
Date Issued
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Report Number
14-02890-143
Date Issued
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Report Number
14-02890-121
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Report Number
14-02890-135
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Report Number
14-02890-133
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Report Number
14-02890-151
Date Issued
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Report Number
14-02384-45
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 12/15/2017
We recommended the Acting Under Secretary for Benefits evaluate options for electronically capturing and analyzing information contained on completed Disability Benefits Questionnaires and implement the most cost effective option. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2017
We recommended the Acting Under Secretary for Benefits revise the remaining 59 public-use Disability Benefits Questionnaires to provide veterans and clinicians adequate notification regarding verification of submitted information.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 7/14/2016
We recommended the Acting Under Secretary for Benefits establish policies and procedures for determining if clinicians who prepare public-use Disability Benefits Questionnaires are private or Veterans Health Administration clinicians.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 3/2/2018
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include steps for obtaining missing public-use Disability Benefits Questionnaires clinician information and verifying clinicians have an active medical license. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 2/25/2016
We recommended the Acting Under Secretary for Benefits revise Veterans Affairs Regional Office quality assurance review methodologies to review appropriate samples of claims including public-use Disability Benefits Questionnaires.
No. 6
to Veterans Benefits Administration (VBA)
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with Disability Benefits Questionnaires’ special-issue indicator requirements.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 5/4/2016
We recommended the Acting Under Secretary for Benefits revise local quality assurance reviews to evaluate Veterans Affairs Regional Office compliance with public-use Disability Benefits Questionnaires’ clinician information completeness requirements.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 7/26/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 9
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to compliance with Disability Benefits Questionnaires’ special-issue indicator and clinician information completeness requirements.
No. 10
to Veterans Benefits Administration (VBA)
Closure Date: 9/20/2017
We recommended the Acting Under Secretary for Benefits require Veterans Benefits Administration’s Compensation Service Disability Examination Management staff to conduct annual validation reviews that select samples from a complete universe of claims with public-use Disability Benefits Questionnaires and focus on public-use Disability Benefits Questionnaires that pose an increased risk of fraud. (Similar to recommendation from 2012 Office of Inspector General audit report)
No. 11
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise policies and procedures to include follow-up actions for inadequate public-use Disability Benefits Questionnaires.
No. 12
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits revise the Systematic Technical Accuracy Review checklists and local quality assurance reviews to evaluate whether claims processors use adequate public-use Disability Benefits Questionnaires instead of obtaining unnecessary Veterans Health Administration compensation and pension examinations.
No. 13
to Veterans Benefits Administration (VBA)
Closure Date: 7/11/2016
We recommended the Acting Under Secretary for Benefits establish procedures requiring Compensation Service Disability Examination Management staff to analyze local quality assurance review results to identify systemic issues related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
No. 14
to Veterans Benefits Administration (VBA)
Closure Date: 9/14/2018
We recommended the Acting Under Secretary for Benefits establish procedures requiring Veterans Affairs Regional Office staff to receive recurring training on systemic issues identified during analyses of local quality assurance review results related to public-use Disability Benefits Questionnaires, including unnecessary Veterans Health Administration compensation and pension examinations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 24,000,000.00
Date Issued
|
Report Number
15-04700-119
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/30/2017
We recommended that designated employees maintain a log of individuals entering the facility between 9:00 p.m. and 5:00 a.m. and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure functionality of negative air pressure systems in all designated rooms or post signage indicating that rooms are not operational and monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure medical waste/biohazard containers are properly secured and monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/9/2017
We recommended that employees secure sensitive patient information at all times and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure competency assessment for employees who prepare compounded sterile products includes an annual written test.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that facility managers ensure completion and documentation of periodic surface sampling in all required areas and monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that facility managers ensure employees perform and document monthly cleaning of ceilings, walls, and storage shelving in all compounding areas and monitor compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that the facility develop and implement a policy that addresses temporary bed locations.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 7/5/2016
We recommended that the facility revise the computed tomography quality control program to include monitoring by a medical physicist at least annually, image quality monitoring, and computed tomography scanner maintenance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 10/2/2016
We recommended that the facility ensure new employees complete suicide prevention training and new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Date Issued
|
Report Number
15-05164-139
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/18/2016
We recommended that the Facility Director ensures the installation and use of an alarm system or panic buttons in high-risk areas at the Pocomoke City VA Clinic.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/13/2017
We recommended that the clinic manager reviews the Pocomoke City VA Clinic’s hazardous materials inventory twice within a 12-month period.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/13/2017
We recommended that providers sign Home Telehealth assessments and treatment plans.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Facility Director ensures that the facility’s written policy include the communication of lab results to patients no later than 14 days from the date on which the results are available to the ordering practitioner.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/20/2016
We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.