Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00084-370 | Healthcare Inspection – Surgical Service Concerns, Fayetteville VA Medical Center, Fayetteville, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that recommendations, if any, from other reviews of the surgical program be implemented.
Closure Date:
2 We recommended that the Facility Director implement procedures to ensure patients are adequately evaluated by medicine and anesthesia providers prior to surgery.
Closure Date:
3 We recommended that the Facility Director ensure that peer reviews are conducted as required when criteria are met.
Closure Date:
4 We recommended that the Facility Director implement processes to ensure that necessary surgical supplies, equipment, and instruments are available, functional, and duplicated as needed.
Closure Date:
5 We recommended that the Facility Director evaluate the organizational structure for parity concerning surgical technician positions.
Closure Date:
6 We recommended that the Facility Director ensure that the surgical post-operative clinic uses the same nurse staffing methodology as other outpatient clinics.
Closure Date:
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| 14-05118-147 | Audit of VBA's Post-9/11 G.I. Bill Tuition and Fee Payments | Audit | ||
1 We recommended the Acting Under Secretary for Benefits improve outreach by periodically requiring Education Liaison Representatives to review Post-9/11 G.I. Bill and Yellow Ribbon Program requirements, the School Certifying Official Handbook, and other available Veterans Benefits Administration training resources with School Certifying Officials to help them submit accurate and complete tuition and fee certifications.
Closure Date:
2 We recommended the Acting Under Secretary for Benefits develop risk profiles for schools that are prone to certification problems, improper payments, and missed recoupments; and implement a process to periodically review and verify the certification information submitted by these schools.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits incorporate improper payment and missed recoupment risk factors into Veterans Benefits Administration’s risk-based system for the prioritization and completion of compliance surveys.
Closure Date:
4 We recommended the Acting Under Secretary for Benefits revise the School Certifying Official Handbook to clarify guidance on allowable book and supply fees.
Closure Date:
5 We recommended the Acting Under Secretary for Benefits review and strengthen Education Service policies and controls regarding the discontinuance and recoupment of payments, repeated classes, and satisfactory academic progress to ensure compliance with Federal regulations and prevent possible education benefits abuse.
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6 We recommended the Acting Under Secretary for Benefits ensure that mitigating circumstances are properly verified and supporting documentation is obtained before tuition repayments are forgiven.
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7 We recommended the Acting Under Secretary for Benefits initiate action to recover identified improper payments when collections are deemed appropriate and reasonable.
Closure Date:
8 We recommended the Acting Under Secretary for Benefits review the identified missed recoupments to determine if collections would be appropriate and reasonable.
Closure Date:
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| 14-00875-325 | Healthcare Inspection – Delay in Care of a Lung Cancer Patient, Phoenix VA Health Care System, Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that primary care providers are notified of specialty evaluations and treatment plans so they can be involved in care coordination.
Closure Date:
2 We recommended that the System Director ensure that staff assesses patient learning needs, barriers, abilities and readiness to learn, and that related education is provided as required by local policy, and monitor for compliance.
Closure Date:
3 We recommended that the System Director ensure that all patients are annually screened for depression, or more frequently as indicated by existing or newly identified risks, and that system manager’s monitor for compliance.
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4 We recommended that the System Director ensure that documentation from non-VA clinical care, including radiology reports, are obtained and available in the electronic health record for review in a timely and consistent manner.
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5 We recommended that the System Director ensure that system staff place consults with urgency based on the needed response time.
6 We recommended that the System Director review facility service agreements and care coordination in order to better care for patients with complex diseases that require multi-specialty intervention.
7 We recommended that the System Director review this case and consult with the Office of Chief Counsel (formerly Regional Counsel) regarding the care provided and take action if appropriate.
Closure Date:
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| 15-01982-113 | Healthcare Inspection - Alleged Inappropriate Opioid Prescribing Practices, Rutherford County Community Based Outpatient Clinic, Rutherfordton, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that primary care providers are able to assess, treat, monitor, and reassess patients on chronic opioid therapy within the appropriate timeframe.
Closure Date:
2 We recommended that the Facility Director ensure that the Veterans¿ Integrated Pain Management Clinic meets non-opioid pain management needs of patients as evidenced by timely consultation completions.
Closure Date:
3 We recommended that the Facility Director consider the clinical and administrative demands of chronic opioid therapy care when determining appropriateness of primary care provider staffing and that staffing plans are in place for planned and unplanned provider vacancies and absences.
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4 We recommended that the Facility Director ensure that benzodiazepine appropriateness evaluations are completed as required for chronic opioid therapy patients with post-traumatic stress disorder.
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5 We recommended that the Facility Director ensure that primary care and mental health providers communicate and coordinate care for post-traumatic stress disorder patients receiving both opioids and benzodiazepines.
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6 We recommended that the Facility Director ensure regular communication between facility leadership and community based outpatient clinic leadership to support consistent high quality care.
Closure Date:
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| 14-04274-418 | Healthcare Inspection – Operating Room Reusable Medical Equipment and Sterile Processing Service Concerns, VA New York Harbor Healthcare System, New York, New York | Hotline Healthcare Inspection | ||
1 We recommended that the System Director charter a team to evaluate the facility's entire process involving reusable medical equipment in accordance with applicable guidelines, integrate reviews' recommendations, and develop an overarching reusable medical equipment management plan.
Closure Date:
2 We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable national and local policies and guidelines for the reprocessing of reusable medical equipment and the preparation of trays and instrument lists.
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3 We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable guidelines to record daily temperature and humidity levels in Sterile Processing Service areas and act upon and document actions when temperature and humidity levels are out of range.
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4 We recommended that the System Director ensure that an ergonomic assessment be made of the physical access and weight of items stored in the operating room Sterile Processing Service storage area and ensure staff safety and compliance with applicable Occupational Safety and Health Administration standards.
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5 We recommended that the System Director ensure training of operating room staff in proper handling of sterile packages and establish a formal process to track and trend issues with packages.
Closure Date:
6 We recommended that the System Director ensure adequate staffing to manage the operational requirements of Sterile Processing Service.
Closure Date:
7 We recommended that the System Director ensure that the operating room and Sterile Processing Service staff implement a reusable medical equipment quality control program consistent with Veteran Health Administration guidelines.
Closure Date:
8 We recommended that the System Director implement measures to improve collaboration and communication within and between operating room and Sterile Processing Service staff.
Closure Date:
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| 15-02707-277 | Review of VBA’s Special Monthly Compensation Housebound Benefits | Audit | ||
1 We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to prevent staff from completing a decision without considering potential eligibility to statutory housebound benefits any time a veteran has a single 100 percent evaluation.
Closure Date:
2 We recommended the then Acting Under Secretary for Benefits conduct a review of all veterans being paid compensation at the housebound rate with a combined evaluation of 90 percent or less and provide certification of completion of the review to the Office of Inspector General.
Closure Date:
3 We recommended the then Acting Under Secretary for Benefits establish a plan to conduct periodic reviews of high-risk cases in which housebound benefits are being paid.
Closure Date:
4 We recommended the then Acting Under Secretary for Benefits implement a plan to provide all decision-makers the updated special monthly compensation training and monitor the effectiveness of the training.
Closure Date:
5 We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to ensure staff discontinue temporary housebound benefits when the criteria are no longer met.
Closure Date:
6 We recommended the then Acting Under Secretary for Benefits remind staff of the requirements to use the Special Monthly Compensation Calculator in all special monthly compensation cases and include the results in the file, and implement a plan to ensure compliance.
Closure Date:
7 We recommended the then Acting Under Secretary for Benefits clarify the meaning of the term substantially confined for housebound in-fact benefits.
Closure Date:
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| 16-00351-453 | OIG Determination of VHA Occupational Staffing Shortages | National Healthcare Review | ||
1 We restated our previous recommendation that the Under Secretary for Health ensure that the Veterans Health Administration develops staffing models for critical need occupations, and we further recommend that the Veterans Health Administration sets forth milestones and a timetable for further critical need occupations’ staffing model development, piloting, and implementation.
Closure Date:
2 We restated our previous recommendation that the Under Secretary for Health review data on regrettable losses and consider implementing measures to reduce such losses.
Closure Date:
3 We recommended that the Under Secretary for Health consider incorporating data that predicts changes in veteran demand for health care into its staffing model.
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4 We recommended that the Under Secretary for Health assess the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.
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| 16-03960-428 | Combined Assessment Program Summary Report – Evaluation of Advance Directives in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently ask inpatients whether they want to discuss advance directives and that facility managers monitor compliance.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when inpatients request a discussion about advance directives, clinicians consistently document that the discussion occurred using only the two Veterans Health Administration standardized note titles for advance directive discussions and that facility managers monitor compliance.
Closure Date:
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| 15-00018-349 | Healthcare Inspection – Lack of Follow-Up Care for Positive Colorectal Cancer Screening, New Mexico VA Health Care System, Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that all patients who experienced delays in notifications of positive fecal immunochemical tests are assessed to determine if appropriate follow-up care was rendered and whether the delays adversely affected the patients¿ clinical outcomes.
Closure Date:
2 We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) regarding the care of the four patients described in this report and any additional patients identified in further review who may have been adversely affected, to determine the appropriate action to take, if any.
Closure Date:
3 We recommended that the Facility Director ensure that providers communicate positive colorectal cancer screening results to patients and document notifications in electronic health records according to Veterans Health Administration test notification policy.
Closure Date:
4 We recommended that the Facility Director ensure that processes are in place to monitor providers’ compliance with Veterans Health Administration colorectal cancer screening policy.
Closure Date:
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| 15-01396-525 | Review of VA’s Award of the PC3 Contracts | Audit | ||
1 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure sufficient oversight on all high-dollar value and complex acquisitions to prevent violations of acquisition regulations and VA policies.
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2 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure critical planning actions—requirements development, market research, and independent government cost estimates are performed and provided to contracting officers, prior to developing requests for proposals.
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3 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) obtain pricing analysis and technical assistance, to ensure quality products and services are procured at fair and reasonable contract prices.
Closure Date:
4 We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) enforce compliance with the VA policy to document all required acquisition decisions in the Electronic Contract Management System.
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15168