Recommendations
2156
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-04347-110 | Review of Physical Security of Information Technology Equipment at the Columbia, South Carolina, VA Regional Office | Review | ||
1 Update the local inventory procedure to include a process for securing information technology equipment when temporary space is needed and for tracking and distributing this equipment, in accordance with federal and VA requirements.
2 Assess the age of all unused information technology inventory to determine what should be used and what should be disposed of based on federal and VA requirements, and take action to address the results.
Total Monetary Impact of All Recommendations
Open: $305,607
Closed: $0
Total: $305,607
| ||||
| 25-00333-137 | Review of Primary Care Providers’ Completion of Electronic Health Record Documentation at the VA Augusta Health Care System in Georgia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 7 VA Southeast Network Director ensures relevant system staff and leaders are trained on state licensing board reporting requirements to include timeliness of reporting.
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| 25-00257-149 | Healthcare Facility Inspection of the VA Wilmington Healthcare System in Delaware | Healthcare Facility Inspection | ||
1 The Chief of Staff ensures facility leaders develop workflows for all services to identify team members’ roles in the process for communicating test results.
| ||||
| 25-03512-141 | Review of the Management of the Homemaker/Home Health Aide Services at the Eastern Oklahoma VA Health Care System in Muskogee and Oklahoma City VA Healthcare System | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures actions are completed to address findings from the electronic health record audit expected to be completed by June 2026 and the annual site visit(s) of the Eastern Oklahoma VA Health Care System homemaker/home health aide program.
2 The Veterans Health Administration Executive Director of Geriatrics and Extended Care, in collaboration with the Veterans Health Administration Geriatrics and Extended Care program manager, provides guidance for Veterans Integrated Service Network and Veterans Health Administration systems’ leaders to evaluate homemaker/home health aide programs in accordance with the Veterans Health Administration Office of Integrated Veteran Care Community Care Field Guidebook and Veterans Health Administration Notice 2024-01, Purchased Home and Community-Based Services.
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| 25-00885-144 | Audit of VISN 8 Supply Chain Management | Audit | ||
1 Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff periodically review unit conversion factors in the Generic Inventory Package to ensure accurate system values and quantities are recorded and then correct any discrepancies.
2 Require medical facility directors in Veterans Integrated Service Network 8 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.
3 Require medical facility directors in Veterans Integrated Service Network 8 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.
4 Ensure medical facility directors in Veterans Integrated Service Network 8 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.
5 Ensure medical facility directors in Veterans Integrated Service Network 8 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated and establish protocols to validate and update equipment location during clinical moves or room changes and ensure equipment items are properly tagged.
6 Require medical facility directors in Veterans Integrated Service Network 8 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.
7 Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated Service Network’s quality control reviews.
Total Monetary Impact of All Recommendations
Open: $3,077,369
Closed: $0
Total: $3,077,369
| ||||
| 25-02834-142 | Audit of VISN 22 Supply Chain Management | Audit | ||
1 Require medical facility directors in Veterans Integrated Service Network 22 to develop and implement procedures to maintain stock within the required thresholds as outlined in Veterans Health Administration Directive 1761.
2 Require medical facility directors in Veterans Integrated Service Network 22 to ensure supply chain staff review and update ABC classification labels on expendable supplies in accordance with Veterans Health Administration guidance and establish a process to routinely verify that labeling aligns with the official ABC classification report.
3 Ensure medical facility directors in Veterans Integrated Service Network 22 develop a process to ensure facility staff safeguard expendable supplies in accordance with Veterans Administration Handbook 0730.
4 Ensure medical facility directors in Veterans Integrated Service Network 22 develop and implement local procedures that require clinical service areas to notify supply chain staff when equipment is relocated, establish protocols to validate and update the equipment location, and ensure equipment items are properly tagged.
5 Require medical facility directors in Veterans Integrated Service Network 22 to ensure facilities conduct annual inventory of nonexpendable equipment.
6 Require medical facility directors in Veterans Integrated Service Network 22 to enforce timely completion of reports of survey in accordance with Veterans Health Administration policy and implement oversight mechanisms to monitor the timely initiation, approval, and closure of reports.
7 Ensure facilities implement corrective actions to effectively address deficiencies identified during the Veterans Integrated System Network’s quality control reviews.
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| 25-00251-124 | Healthcare Facility Inspection of the VA Dayton Healthcare System in Ohio | Healthcare Facility Inspection | ||
1 The Director ensures Environmental Management Services staff keep patient care areas clean and well maintained.
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| 25-01015-138 | Audit of Consult Timeliness for VA and Community Care | Audit | ||
1 Conduct a strategic business evaluation of the process used by VA medical facilities’ scheduling departments to determine whether alternatives could improve consult processing, scheduling efficiency, and timeliness.
2 Establish procedures to track and provide oversight of consults that schedulers have not acted on to schedule and prioritize processing of those consults when identified.
Closure Date:
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| 25-01014-139 | Audit of Veterans’ Community Care Eligibility Determinations | Audit | ||
1 Establish and use agreements with other VA medical facilities to help identify and schedule direct care when local services are not available.
2 Assess options to improve the scheduling process and system to provide schedulers with access to community care provider appointment availability when discussing care options with wait time–eligible veterans.
3 Review services in the Consult Toolbox to make sure it accurately reflects available services and avoids inaccurate eligibility determinations.
4 Reinforce requirements for schedulers to review scheduling systems to identify the next available date for appointments and input that information in the Consult Toolbox.
5 Implement a process to verify that schedulers check all community care eligibility criteria for all veterans.
6 Emphasize to schedulers at least annually the proper methods (including the use of opt-out codes) to document when veterans opt out of community care.
Total Monetary Impact of All Recommendations
Open: $1,744,845,232
Closed: $0
Total: $1,744,845,232
| ||||
| 25-02152-136 | Review of Ear, Nose, and Throat Surgery-Related Sterile Processing Services Concerns at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Michael E. DeBakey VA Medical Center Director uses available resources to help recruit and hire an assistant chief of Sterile Processing Services.
2 The Michael E. DeBakey VA Medical Center Director, in conjunction with the chief of Sterile Processing Services, reviews reusable medical device inventory management and oversight processes to ensure compliance with Veterans Health Administration requirements, identifies deficiencies, and takes action as warranted.
3 The Michael E. DeBakey VA Medical Center Director reviews processes to track issue briefs related to surgery cancellations resulting from reusable medical device issues from initiation to closure, identifies deficiencies, and takes action as necessary.
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15461