Recommendations
2132
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-00153-47 | Review of Automated Decisions for Veterans’ Service-Connected Death Claims | Review | ||
1 Strengthen and monitor the automation process to ensure that automated Dependency and Indemnity Compensation rating decisions and notifications fully comply with all legal requirements and procedural guidance.
2 Ensure the Pension and Fiduciary Service revises the quality review checklist for automated death benefits decisions so that those decisions undergo the same scrutiny as traditionally processed claims.
3 Consult with VA’s Office of General Counsel to determine whether the modernization plan submitted to Congress—regarding service-connected death benefit grants—complies with section 701(b) of the PACT Act and take appropriate corrective action if needed.
Total Monetary Impact of All Recommendations
Open: $2,727,764
Closed: $0
Total: $2,727,764
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| 25-02364-84 | Review of VBA’s Recurring Benefits for Beneficiaries Aged 100 Years or Older | Review | ||
1 Take corrective action on the remaining three of seven instances that led to about $612,000 in improper payments.
2 Update requirements provided to the VA Hines Information Technology Center to ensure all foreign beneficiaries, including those with an address in the Philippines, are included in the annual end product generation.
Closure Date:
3 Update the Veterans Benefits Administration’s Adjudication Procedures Manual to clarify and strengthen the actions claims processors should take to verify foreign beneficiaries are alive.
4 Ensure jurisdiction guidance for routine reviews for residents in the Philippines is clearly communicated to all regional offices.
5 Provide guidance to assist claims processors in verifying information in the Veterans Benefits Administration’s systems compared to the results from the Social Security Administration inquiry results.
6 Update the Adjudication Procedures Manual to require claims processors to upload the Social Security Administration inquiry results to beneficiaries’ records.
Total Monetary Impact of All Recommendations
Open: $612,000
Closed: $0
Total: $612,000
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| 25-02464-105 | Review of Responsiveness to Patient Care Concerns, and Credentialing and Supervision of a Nurse Practitioner and Physician Assistant at the VA Loma Linda Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA Loma Linda Healthcare System Director ensures the Chief of Staff signs peer review designation memoranda within three days of determining a peer review is needed as outlined in Veterans Health Administration policy.
2 The VA Loma Linda Healthcare System Director ensures that focused professional practice evaluations for initial appointments and additional privileges are completed in accordance with Veterans Health Administration policy and monitors for compliance.
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| 24-03186-99 | Review of Community Care Consult Management at the VA Fayetteville Coastal Healthcare System in North Carolina | Hotline Healthcare Inspection | ||
1 The VA Fayetteville Coastal Healthcare System Director confirms full implementation of the VA Community Care Oversight and Consult Management Council.
2 The Under Secretary for Health reviews practices and procedures for managing consults to identify and prioritize appointment scheduling for patients with serious health conditions (high‑priority consults), such as cancer, and provide direction to the field on the process to use to make this determination.
3 The VA Fayetteville Coastal Healthcare System Director directs the development and implementation of community care service standard operating procedures to address identification and management of high-priority consults, timeliness of consult processing, and care coordination that aligns with direction provided by Veterans Health Administration’s Integrated Veterans Care program.
4 The VA Fayetteville Coastal Healthcare System Director ensures staff are trained in all newly developed community care standard operating procedures and that adherence to policy and practice is monitored.
5 The VA Fayetteville Coastal Healthcare System Director confirms completion of a review of quality management processes to ensure quality management staff, when reviewing patient safety events, consider potential system issues and, if present, recommend they be addressed using other quality management reviews.
6 The VA Fayetteville Coastal Healthcare System Director ensures local processes are in place, including assigned roles and responsibilities, to manage Office of Inspector General case referrals in compliance with VA Directive 0701, Office of Inspector General Hotline Complaint Referrals.
7 The VA Fayetteville Coastal Healthcare System Director confirms reasonable efforts to conduct an institutional disclosure with the patient regarding circumstances that led to the delay in the diagnosis of and treatment for lung cancer are made and, if a disclosure is completed, that it is documented in the electronic health record.
Closure Date:
8 The Under Secretary for Health assesses the electronic health record reviews completed by the system in response to the community care backlog to determine if a more comprehensive review is warranted with appropriate disclosure to patients placed at risk or harmed as a result of a delay in action on their community care consult, and takes action accordingly.
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| 25-00373-95 | Inspection of Select Vet Centers in North Atlantic District 1 Zone 4 | Vet Center Inspection Program | ||
1 District leaders and the Prince George’s County Vet Center Director collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation in the mental health executive council, take action as indicated, and monitor compliance.
2 District leaders and the Prince George’s County, Fayetteville, and Chesapeake Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.
3 District leaders and the Prince George’s County and Fayetteville Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Prince George’s County, Fayetteville, and Chesapeake Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
5 District leaders and the Prince George’s County and Chesapeake Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Prince George’s County Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Fayetteville and Chesapeake Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
8 District leaders and the Fayetteville Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.
9 District leaders and the Chesapeake Vet Center Director determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
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| 25-00372-96 | Inspection of Select Vet Centers in North Atlantic District 1 Zone 3 | Vet Center Inspection Program | ||
1 District leaders and the Lancaster Vet Center Director determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.
Closure Date:
2 District leaders and the White Oak Vet Center Director determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.
Closure Date:
3 District leaders and the Dubois, Lancaster, and White Oak Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
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| 25-00371-97 | Inspection of Select Vet Centers in North Atlantic District 1 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Buffalo Vet Center Director collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation in the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Buffalo, Nassau, and Syracuse Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.
3 District leaders and the Buffalo, Nassau, and Syracuse Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.
4 District leaders and the Buffalo and Nassau Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Syracuse Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.
9 District leaders and the Nassau and Syracuse Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
10 District leaders determine reasons why there are discrepancies in the vet center address on VA and public-facing websites and ensure all websites include correct location information.
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| 25-00369-98 | Inspection of Select Vet Centers in North Atlantic District 1 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the New Haven Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
2 District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented to complete consultation requirements, and monitor compliance.
3 District leaders and the Sanford Vet Center Director determine reasons for noncompliance with completing monthly reviews of 10 percent of active client records for each counselor’s caseload, ensure completion and monitor compliance.
Closure Date:
4 District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with employees completing select training in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the New Haven, Sanford, and Providence Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
6 District leaders and the New Haven and Providence Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the New Haven Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Sanford Vet Center Director determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
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| 25-00241-73 | Healthcare Facility Inspection of the VA Palo Alto Health Care System in California | Healthcare Facility Inspection | ||
1 The Executive Medical Center Director ensures clinical staff can open all doors to shared bathrooms.
2 The Executive Medical Center Director ensures staff keep exterior doors closed to minimize risk to wandering patients.
3 The Executive Medical Center Director ensures staff store clean and dirty equipment and supplies separately.
Closure Date:
4 The Executive Medical Center Director ensures each service has workflows to communicate test results.
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| 25-00208-64 | Healthcare Facility Inspection of the VA Loma Linda Healthcare System in California | Healthcare Facility Inspection | ||
1 Facility leaders ensure the community living center’s dementia unit shower room is clean and free from hazards, and that leaders conduct a risk assessment to determine the need for other safety measures.
Closure Date:
2 The Medical Center Director ensures facility staff conduct a privacy assessment and take actions to protect patient information in the Emergency Department.
Closure Date:
3 Facility leaders ensure all eyewash stations are clean and function properly.
Closure Date:
4 The Medical Center Director ensures the facility has a written policy for communication of test results.
5 The Chief of Staff and Associate Director of Patient Care Services ensure leaders in each service develop written service-level workflows that outline the process for staff to communicate test results to providers and patients.
6 The Veterans Integrated Service Network Director ensures executive leaders implement a process to monitor actions related to Veterans Health Administration policy changes.
7 The Medical Center Director ensures the Chief of Staff and Associate Director of Patient Care Services review performance metrics for test result communications and take action for identified deficiencies.
8 The Medical Center Director ensures executive leaders attend Quality and Patient Safety Council meetings.
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15353