Recommendations
2229
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 26-00685-08 | Healthcare Facility Inspection of the VA Salt Lake City Healthcare System in Utah | Healthcare Facility Inspection | ||
1 The Veterans Integrated Service Network Director takes action so that executive leaders establish trust and a culture of safety, in accordance with the Veterans Health Administration High Reliability Organization (HRO) Reference Guide.
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| 26-00063-07 | Healthcare Facility Inspection of the VA Chicago Healthcare System in Illinois | Healthcare Facility Inspection | ||
1 The Medical Center Director develops an action plan with community care leaders to meet the requirement for staff to schedule appointments within seven days, as outlined in the Veterans Health Administration’s Consult Timeliness Standard Operating Procedure.
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| 25-01406-224 | Audit of Caregiver Support Program Appeals Processes | Audit | ||
1 Develop and implement timeliness goals for completing Appeals Modernization Act decision reviews for the Program of Comprehensive Assistance for Family Caregivers to make sure that claims are assigned and acted upon in accordance with these measures.
2 Develop a plan to address the backlog of Appeals Modernization Act decision reviews for the Program of Comprehensive Assistance for Family Caregivers and report progress routinely and transparently to inform veterans.
3 Update language in VA Form 10‑305 and VHA Notice 2025-09 to clarify that veterans or caregivers must file a Program of Comprehensive Assistance for Family Caregivers supplemental claim within one year from the date of the decision notification letter to be eligible for the same effective date as the date of their initial application for any benefits granted in accordance with the law (38 U.S.C. § 5110).
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| 25-00148-252 | Audit of the Medical Care Collections Fund for VA-Provided Care | Audit | ||
1 Provide findings on the analysis of why Veterans Health Information Systems and Technology Architecture reports do not capture all patient encounters with a reasons-not-billable code and implement a plan to capture all encounters being reported outside that system.
2 Provide guidance and oversight to ensure reasons-not-billable reports have accurate and complete patient encounter data.
3 Review encounters excluded from Veterans Health Information Systems and Technology Architecture reasons-not-billable reports for potentially billable encounters and, if appropriate, bill insurance companies for revenue for the period allowed by 38 U.S.C. § 1729.
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| 25-03303-266 | Review of Accuracy of Claims Processors’ Disability Evaluation Decisions for Painful Scars | Review | ||
1 Review and correct the processing errors on decisions the Office of Inspector General team identified so that they are compliant with 38 C.F.R. § 4.118 and consistent with the Adjudication Procedures Manual.
2 Initiate and provide a timeline for revising the “Scars/Disfigurement” disability benefits questionnaire to clearly elicit information needed for claims processors to determine whether subjective reports of scar pain or tenderness are supported by objective evidence, as required, to establish a compensable evaluation for a painful scar under the Adjudication Procedures Manual.
Closure Date:
3 Determine and complete additional actions so that employees understand how to accurately evaluate painful scars under 38 C.F.R. § 4.118 and in accordance with the Adjudication Procedures Manual.
Total Monetary Impact of All Recommendations
Open: $5,584,470
Closed: $0
Total: $5,584,470
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| 26-00041-05 | Healthcare Facility Inspection of the VA Phoenix Health Care System in Arizona | Healthcare Facility Inspection | ||
1 The Chief of Staff and Associate Director for Patient Care Services develop written service-level workflows that outline staff members’ roles in the process to communicate test results to patients, in accordance with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
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| 26-00044-209 | Healthcare Facility Inspection of the VA Maryland Health Care System in Baltimore | Healthcare Facility Inspection | ||
1 The Associate Director requires bathroom and shower emergency pull cords to be present, accessible, and functional, in accordance with the National Fire Protection Association’s NFPA 99 Health Care Facilities Code.
Closure Date:
2 The Chief of Staff develops written workflows for each service consistent with Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
Closure Date:
3 The Chief of Staff develops and implements a standardized process to routinely assess panel size and efficiency, as required by Veterans Health Administration Directive 1406(3), Patient Centered Management Module (PCMM) for Primary Care.
Closure Date:
4 The Director develops and implements a process to meet the seven‑day scheduling requirement in Veterans Health Administration’s Consult Timeliness Standard Operating Procedure.
Closure Date:
5
The Director considers a security assessment to identify risks at the Baltimore VA Clinic, in accordance with VA Handbook 0730/4, Security and Law Enforcement.
Closure Date:
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| 25-00239-196 | Healthcare Facility Inspection of the VA Nebraska-Western Iowa Health Care System in Omaha | Healthcare Facility Inspection | ||
1 The Director takes appropriate steps to maintain clean patient care areas and properly manage biohazards, in accordance with Veterans Health Administration Directive 1131, Management of Infectious Diseases and Infection Prevention and Controls Programs.
2 The Director takes appropriate steps so the facility’s annual assessment for Legionella disease prevention includes the Papillion community living center, as required by Veterans Health Administration Directive 1061(4), Prevention of Health Care-Associated Legionella Disease and Scald Injury from Water Systems.
3 The Chief of Staff takes the appropriate steps for leaders to assess the facility’s pharmaceutical waste disposal processes and reeducate staff on safe handling and disposal practices, in accordance with the facility’s Regulated Waste Materials Management policy and Pharmaceutical Return, Waste, and Disposal Standard Operating Procedure.
4 The Chief of Staff and Associate Director for Patient Care/Nurse Executive take the appropriate steps so leaders create service-level workflows that outline staff roles for communicating test results to patients and providers, as required by Veterans Health Administration Directive 1088(1), Communicating Test Results to Providers and Patients.
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| 26-01435-02 | Review of Roll-up Findings on Discharge Instructions and Risk-Benefit Discussions from Inspections of VA Inpatient Mental Health Care | Mental Health Inspection Program | ||
1 The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans consistently include appointment locations in easy-to-understand language.
2 The Under Secretary for Health implements corrective actions to ensure discharge instructions for veterans who received inpatient mental health care include the purpose for each medication listed and do not include medical abbreviations.
3 The Under Secretary for Health implements corrective actions to ensure risk-benefit discussions occur for newly prescribed medications.
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| 26-00047-288 | Healthcare Facility Inspection of the VA Pittsburgh Healthcare System in Pennsylvania | Healthcare Facility Inspection | ||
1 The Director takes appropriate action for employees to keep patient care areas clean as required by Veterans Health Administration Directive 1608(1), Comprehensive Environment of Care Program and clean storerooms as required by Veterans Health Administration Directive 1761, Supply Chain Management Operations.
2 The Director takes appropriate action for employees to inspect and test all medical equipment as required by The Joint Commission standard PE [Physical Environment] 04.01.01.
3 The Director takes appropriate action so pharmaceutical waste containers are provided and accessible, and trains employees on container use as required by Veterans Health Administration Directive 1850.06(1), Waste Management Program.
4 The Director takes appropriate action so employees secure power strips as required by National Fire Protection Association’s Health Care Facilities Code, NFPA 99 and electrical cords are connected to prevent pulling or straining as required by National Electrical Code, NFPA 70.
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15778