Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00790-417 | Review of Alleged Wasted Funds at Consolidated Patient Account Centers for Windows Enterprise Licenses | Audit | ||
1 We recommended the Assistant Secretary for Information and Technology implement a policy to ensure cost-effective utilization of information technology equipment, installed software, and services and ensure coordination of acquisitions with affected VA organizations. This will help ensure VA’s operating framework and organizational needs are considered prior to acquisitions.
Closure Date:
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| 16-03330-91 | Administrative Investigation - Conduct Prejudicial to the Government and Misuse of Position in the VA Office of General Counsel, Washington, DC | Administrative Investigation | ||
1 We recommend that VA’s General Counsel confer with the Office of Human Resources to determine the appropriate administrative action to take, if any, against Mr. Burch.
2 We recommend that VA’s General Counsel conduct a review of the CFBNP Steering Committee charter, membership, and activities, to determine whether members of the committee have engaged in a conflict of interest, or created the appearance of one, through the members’ association with non-Governmental Organizations, as defined in VA Directive 0008, or otherwise, and take the appropriate corrective action.
Closure Date:
3 We recommend that VA’s General Counsel extend the “covered positions” requirement for filing of Confidential Financial Disclosure Reports under 5 C.F.R. § 2634.904(a) to all attorneys employed by VA.
Closure Date:
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| 15-05180-75 | Healthcare Inspection – Mental Health-Related Concerns, W. G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director implement strategies to enhance communication and coordination across clinical areas for patients with High Risk for Suicide Patient Record Flags.
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| 14-02890-72 | Review of Alleged Wait-Time Manipulation at VHA's Southern Arizona VA Health Care System | Audit | ||
1 We recommended the VA Desert Pacific Healthcare Network Director review the training records of all SAVAHCS schedulers to ensure their training is compliant with Veterans Health Administration scheduling policy.
Closure Date:
2 We recommended the VA Desert Pacific Healthcare Network Director ensure that SAVAHCS schedulers comply with current VHA policy regarding scheduling policies and practices.
Closure Date:
3 We recommended the VA Desert Pacific Healthcare Network Director perform an administrative investigation to determine who directed former Business Service Line officials to create and use training materials that did not comply with VA scheduling policy and take appropriate disciplinary action for any individuals involved.
Closure Date:
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| 15-05255-422 | Audit of VHA’s Consolidated Mail Outpatient Pharmacy Program | Audit | ||
1 We recommended the Under Secretary for Health ensure the Consolidated Mail Outpatient Pharmacies¿ Logistics Officer and Director or Associate Director review all inventory adjustments and approve adjustment documentation monthly as required by CMOP Inventory Management and Control national policy.
Closure Date:
2 We recommended the Under Secretary for Health ensures Consolidated Mail Outpatient Pharmacy National Office implements a mechanism to validate self-reported data to ensure the reliability of its core quality metrics.
Closure Date:
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| 14-04898-290 | Healthcare Inspection – Teleradiology Concerns, VA Roseburg Healthcare System, Roseburg, Oregon | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director conduct a quality review of the imaging study interpretations completed during the time of the unsigned Memorandum of Understanding referenced in this report.
Closure Date:
2 We recommended that the System Director strengthen processes to ensure the Radiology Services is fully integrated into the system's formal peer review program.
Closure Date:
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| 15-00506-420 | Healthcare Inspection – Nurse Staffing and Patient Safety Reporting Concerns, VA Roseburg Healthcare System, Roseburg, Oregon | Hotline Healthcare Inspection | ||
1 We recommended that the System Director strengthen processes to ensure staffing levels are analyzed and documented in applicable safety and quality of care reviews and annually reported to leadership.
Closure Date:
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| 15-04672-342 | Review of Alleged Consult Management Issues at the Phoenix VA Health Care System | Audit | ||
1 We recommended the Under Secretary for Health update the Veterans Health Administration Consult Policy.
2 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System communicate consult policies and procedures to all facility staff and providers to ensure consistent procedures and responsibilities to effectively manage and schedule consults.
3 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System develop a routine review of closed consults to ensure staff are appropriately discontinuing and documenting consults in accordance with national and local policy.
Closure Date:
4 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure respective services follow up with the patients identified in this review for appropriate action.
5 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Chiropractic Services review all consults canceled by the service since January 1, 2015, for appropriate action.
Closure Date:
6 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System ensure that the care of the patient identified in the reported case summary is evaluated, takes action, if appropriate, and confers with Regional Counsel regarding the appropriateness of disclosures to patients and families.
7 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System develop a mechanism to ensure that Quality, Safety, and Improvement services appropriately review deceased patients’ records with an open consult, and staff timely and appropriately close the consult upon verification of death by Decedent Affairs.
8 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure services assign and maintain appropriate and sufficient clinical staff to receive and review consults within target time frames.
Closure Date:
9 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Human Resources and specialty care services fill vacant medical support assistant positions responsible for scheduling consults in specialty care services to ensure sufficient resources to manage and schedule consults.
Closure Date:
10 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System pursue an automated process to ensure Vascular Lab results are entered in the electronic medical records in order to eliminate reliance on printed lab results.
Closure Date:
11 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Vascular Service review all incomplete Vascular Lab consults to identify and address all potential lost lab results.
Closure Date:
12 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure clinics coordinate with clinic informatics services to develop a mechanism to routinely identify and address open consults in which the corresponding appointment was already completed.
13 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System assign sufficient staff to manage non-VA care and Choice consults and appointments.
Closure Date:
14 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure non-VA care develop a process to routinely follow up with those patients with open community care consults older than 120 days to determine if they received the requested care.
Closure Date:
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| 14-02890-425 | Review of an Alleged Radiology Exam Backlog at VHA’s W.G. (Bill) Hefner VAMC in Salisbury, NC | Audit | ||
1 We recommended the W.G. (Bill) Hefner VA Medical Center Directorrequire staff to review all unscheduled radiology exam orders that are30 days past the clinically indicated date and either cancel the orders ifthe exams are not needed or ensure the exams are scheduled.
Closure Date:
2 We recommended the W.G. (Bill) Hefner VA Medical Center Directormake unscheduled urgent and STAT (immediate) orders a priority in thestaff’s review of unscheduled radiology orders and ensure staff determinewhether any potential harm has occurred to patients due to the delays incare.
Closure Date:
3 We recommended the VA Mid-Atlantic Health Care Network Directorensure that the W.G. (Bill) Hefner VA Medical Center develops a plan toaddress existing demand for Radiology exams and ensures future patientsreceive access to exams in accordance with VHA policy.
Closure Date:
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| 15-00650-423 | Review of Alleged Waste of Funds at VHA's Madison VA Medical Center | Audit | ||
1 We recommended the Veterans Integrated Service Network 12 Acting Director ensure management at the William S. Middleton Veterans Hospital complies with the facility policy requiring all equipment requests contain sufficient and accurate information to justify the acquisition request.
2 We recommended the Veterans Integrated Service Network 12 Acting Director ensure all laser lead extractors within the Veterans Integrated Service Network are being utilized to the extent possible.
Closure Date:
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15168