Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-01818-213 | Review of Alleged Improperly Sole Sourced Ophthalmology Service Contracts at the Phoenix VA Health Care System | Audit | ||
1 We recommended the Procurement and Logistics Office, Service Area Office West Director ensure Network Contracting Office 18 contracting officers maintain required contracting documentation in the Electronic Contract Management System, as required by VA Procurement Policy Memorandum, Mandatory Usage of VA's Electronic Contract Management System.
Closure Date:
2 We recommended the Phoenix VA Health Care System Director ensure the just over $12.4 million in unauthorized commitments are ratified in accordance with VA Directive 7401.7, Unauthorized Commitments and Ratification.
Closure Date:
3 We recommended the Phoenix VA Health Care System Director develop a business case to evaluate the hiring of VA ophthalmologists and the use of Non-VA Care options, such as the Patient-Centered Care Program and as defined in the Veterans Access, Choice, and Accountability Act.
Closure Date:
4 We recommended the Phoenix VA Health Care System Director ensure staff are aware of Federal Acquisition Regulation sections 6.301 and 3.101-1 related to sole-source contracting and standards of conduct.
Closure Date:
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| 15-02189-336 | Review of Alleged Waste of Funds on a Cloud Brokerage Service Contract | Audit | ||
1 We recommended the Assistant Secretary for Information and Technology implement improved controls to ensure the effective oversight of information technology projects and compliance with information technology project management procedures in order to ensure delivery of value.
Closure Date:
2 We recommended the Assistant Secretary for Information and Technology enforce the use of the Project Management Accountability System or Veteran-focused Integration Process on all Office of Information and Technology software development projects to ensure that such efforts will provide an adequate return on investment.
Closure Date:
3 We recommended the Assistant Secretary for Information and Technology establish oversight mechanisms to ensure all VA-developed software costs are funded with Information Technology Systems appropriations.
Closure Date:
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| 15-03401-76 | Review of Alleged Human Resources Delays at the Atlanta VA Medical Center | Audit | ||
1 We recommended the Medical Center Director assess the human resources program at the Atlanta VA Medical Center to develop an action plan to ensure all medical center staff have appropriate background investigations and determinations are accurately recorded.
Closure Date:
2 We recommended the Medical Center Director ensure all suitability adjudicators receive the mandatory training and background investigation required for the position.
Closure Date:
3 We recommended the Medical Center Director provide training to all human resources staff on the requirements of the personnel suitability program to include generally accepted resources and tools to standardize the processing of background investigations.
Closure Date:
4 We recommended the Medical Center Director ensure the Atlanta VA Medical Center human resources staff, to include the Drug-Free Workplace Program Coordinators and Medical Review Officers, are properly trained on the requirements of the Drug-Free Workplace Program and the responsibilities of their positions.
Closure Date:
5 We recommended the Medical Center Director review the Drug-Free Workplace Program on a regular basis to ensure compliance with regulations and that employees hired during screening gaps are subject to corrective testing.
Closure Date:
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| 15-04673-333 | Review of VHA’s Implementation of the Veterans Choice Program | Audit | ||
1 We recommended the Under Secretary for Health streamline processes and procedures for accessing care under the Veterans Choice Program.
Closure Date:
2 We recommended the Under Secretary for Health develop accurate forecasts of demand for care purchased in the community.
Closure Date:
3 We recommended the Under Secretary for Health simplify requirements for network providers to bill for services under the Veterans Choice Program.
Closure Date:
4 We recommended the Under Secretary for Health ensure eligible veterans are not financially liable for the full cost of treatment authorized under the Veterans Choice Program.
Closure Date:
5 We recommended the Under Secretary of Health ensure community providers are paid in a timely manner under the Veterans Choice Program.
Closure Date:
6 We recommended the Under Secretary for Health review the Veterans Choice Program to determine if growth of provider networks is being limited by allowing reimbursement below Medicare rates.
Closure Date:
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| 15-00075-449 | Combined Assessment Program Follow-Up Review of Environment of Care at the VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that surgical intensive care unit floors are clean and that damaged bathroom fixtures on the surgical intensive care unit are repaired or replaced.
Closure Date:
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| 14-04578-371 | Audit of VA’s Recruitment, Relocation, and Retention Incentives | Audit | ||
1 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to ensure recruitment and relocation incentives are fully justified and authorized before being included on vacancy announcements for hard-to-fill positions or before the final selectee is identified in cases where a position is not filled through a vacancy announcement.
Closure Date:
2 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for the Corporate Senior Executive Management Office to ensure Senior Executive Service recruitment and relocation incentives are fully justified and authorized before being included on vacancy announcements for hard-to-fill positions or before the final selectee is identified in cases where a position is not filled through a vacancy announcement.
Closure Date:
3 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor compliance with its employee certification requirement before relocation incentives are authorized for payment.
Closure Date:
4 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls to monitor the Corporate Senior Executive Management Office’s compliance with the employee certification requirement before Senior Executive Service relocation incentives are authorized for payment.
Closure Date:
5 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor facilities’ compliance with developing workforce and succession plans to reduce the risk of long-term reliance on retention incentives.
Closure Date:
6 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls to monitor the Corporate Senior Executive Management Office’s compliance with developing workforce and succession plans to reduce the risk of long-term reliance on retention incentives for Senior Executives.
Closure Date:
7 We recommended the Assistant Secretary for Human Resources and Administration monitor the Corporate Senior Executive Management Office to ensure its technical review and recommendations to the VA Chief of Staff regarding Senior Executive Service incentives are prudent and in full compliance with VA Handbook 5007/46.
Closure Date:
8 We recommended the Assistant Secretary for Human Resources and Administration assess the feasibility of limiting the number of consecutive years employees in specific occupations or groups of employees in specific occupations can receive retention incentive payments.
Closure Date:
9 We recommended the Assistant Secretary for Human Resources and Administration review and update procedures and add internal controls for Administrations to monitor facilities’ compliance with VA Handbook 5007/46 requirements to initiate debt collection from individuals who did not fulfill their recruitment, relocation, or retention incentive service obligations.
Closure Date:
10 We recommended the Assistant Secretary for Human Resources and Administration examine the capabilities of the HR Smart personnel system to determine the extent to which it is possible to develop an incentive-specific automated alert that notifies Human Resources personnel when employees have outstanding recruitment, relocation, or retention incentive service obligations.
Closure Date:
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| 14-02890-352 | Review of Alleged Improper Non-VA Community Care Consult Practices at Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Audit | ||
1 We recommended the Director, Ralph H. Johnson VAMC, initiate an additional clinical review regarding the patient identified in this report, and take action as appropriate.
Closure Date:
2 We recommended the Director, Ralph H. Johnson VAMC, ensure that consults that were not acted on within 7 days can be tracked and managed in accordance with national policy.
Closure Date:
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| 15-02278-415 | Review of Alleged Misuse of VA Funds at the VA Pittsburgh Healthcare System | Audit | ||
1 We recommended the Veterans Integrated Service Network 4 Director ensure the VA Pittsburgh Healthcare System conduct annual reviews to ensure its resident meal plans are appropriate and supported by adequate documentation.
Closure Date:
2 We recommended the Veterans Integrated Service Network 4 Director ensure the VA Pittsburgh Healthcare System evaluate purchasing meals internally from the Veterans Canteen Service as an alternative to commercial sources.
Closure Date:
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| 15-04247-111 | Healthcare Inspection – Review of Antimicrobial Stewardship Programs in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health implement procedures to ensure that facilities comply with Veterans Health Administration Directive 1031 requirements, including the completion of annual evaluations, designation of provider and pharmacy champions, staff education, and the provision of adequate dedicated staffing and resources.
Closure Date:
2 We recommended that the Under Secretary for Health require that Veterans Health Administration facilities track and generate clinical outcome reports on antibiotic use.
Closure Date:
3 We recommended that the Under Secretary for Health consider implementing standardized tools and definitions for antimicrobial stewardship data and a uniform reporting system to permit analysis of comparable information over time.
Closure Date:
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| 14-03434-102 | Healthcare Inspection – Review of Complaints Regarding Mental Health Services Clinical and Administrative Processes, VA St. Louis Health Care System, St. Louis, Missouri | Hotline Healthcare Inspection | ||
1 We recommended that the Acting System Director ensure that Mental Health Service reviews daily psychiatric patient care activity and determine if productivity is consistent with work relative value unit-based productivity and meets reasonable expectations for number of patients treated.
2 We recommended that the Acting System Director ensure that staff psychiatrists’ scheduling grids are consistent with expected patient care activity.
3 We recommended that the Acting System Director ensure that processes be strengthened to review and rectify psychiatry staff’s Current Procedural Terminology coding errors.
Closure Date:
4 We recommended that the Acting System Director ensure that processes be strengthened for timely response to mental health clinic group treatment patient referrals.
Closure Date:
5 We recommended that the Acting System Director ensure that mental health staff adequately assess and document treatment needs and follow-up arrangements for unscheduled (walk-in) patients.
Closure Date:
6 We recommended that the Acting System Director ensure that facsimile machine numbers provided to referral sources are functional and appropriately located for timely response.
7 We recommended that the Acting System Director strengthen the Compensation and Pension evaluation documentation processes to enhance accuracy of information.
8 We recommended that the Acting System Director ensure that processes be strengthened to include patients in treatment planning when they are transferred to another clinic.
Closure Date:
9 We recommended that the Acting System Director ensure that peer reviews are inclusive of all relevant clinicians and timely and that managers take appropriate follow-up actions, if indicated.
Closure Date:
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15168