Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-04945-331 | Review of Alleged Mismanagement of the Ambulette Services at the New York Harbor Healthcare System | Audit | ||
1 We recommended the Under Secretary for Health implement an oversight process to ensure Integrated Oversight Process reviews arecompleted in accordance with established policies.
Closure Date:
2 We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, develop a mechanism to ensure effective coordination between acquisition personnel when transferring contracting responsibilities.
Closure Date:
3 We recommended the Head of Contracting Activity, Veterans Health Administration, Service Area Office East, implement a process to ensure all acquisition personnel record contracting actions in the Electronic Contract Management System.
Closure Date:
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| 16-01708-340 | Healthcare Inspection – Review of Primary Care Ghost Panels, Veterans Integrated Service Network 23, Eagan, Minnesota | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Acting Director ensure that Facility Directors reassign or redistribute primary care patients to other primary care teams as required by the Veterans Health Administration and monitor compliance.
Closure Date:
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| 15-05490-367 | Healthcare Inspection – Reported Primary Care Staffing at St. Cloud VA Health Care System, Veterans Integrated Service Network 23, Eagan, Minnesota | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Veterans Integrated Service Network Director ensure that the Facility Director reviews Primary Care Management Module data and reports and takes steps to follow Veterans Health Administration guidance for primary care provider panel sizes across the system.
Closure Date:
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| 16-02729-350 | Review of Alleged Waste of Funds at the VA Medical Center in Detroit, Michigan | Audit | ||
1 We recommended the Veterans Integrated Service Network 10 Acting Director require the Detroit VA Medical Center strengthen policy to ensure the proper equipment is purchased at the appropriate time when planning projects requiring the purchase of equipment.
Closure Date:
2 We recommended the Veterans Integrated Service Network 10 Acting Director ensure the Detroit VA Medical Center develop and implement a plan to use the purchased televisions or make them available to other VA facilities to use.
Closure Date:
3 We recommended the Veterans Integrated Service Network 10 Acting Director consult with the appropriate VA financial and legal officials to determine whether the Detroit VA Medical Center violated the bona fide needs rule, and if a violation occurred, take the steps necessary to remedy the violation.
Closure Date:
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| 15-03688-304 | Audit of VA’s Green Management Program Solar Panel Projects | Audit | ||
1 We recommend the Interim Assistant Secretary for Management strengthen controls to ensure facility officials inform officials in the contracting office of potential conflicts between solar panel projects and other projects.
Closure Date:
2 We recommended the Interim Assistant Secretary for Management identify and share best practices for executing timely interconnection agreements with utilities based on continued collaboration with other Federal agencies.
Closure Date:
3 We recommended the Interim Assistant Secretary for Management implement controls to periodically compare actual and expected solar power generation data to ensure the solar panel system is performing as planned.
Closure Date:
4 We recommended the Interim Assistant Secretary for Management conduct a lessons learned assessment for solar project delays and implement additional controls to ensure future solar panel projects are properly planned and managed.
Closure Date:
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| 16-01613-326 | Combined Assessment Program Summary Report – Evaluation of Surgical Complexity Support Services in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health ensure that the Veterans Health Administration establishes system-wide requirements for competency assessment and validation, including frequency, for nursing employees who provide post-anesthesia care after operational hours.
Closure Date:
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| 15-04248-305 | Audit of Modular Ramps Purchased by the Malcom Randall VA Medical Center Gainesville, Florida | Audit | ||
1 We recommended the Malcom Randall VA Medical Center Director develop and implement a quality review process to ensure staff only award purchase orders for modular ramps that are Americans with Disabilities Act compliant and perform follow-up with vendors to ensure installed ramps comply with the Americans with Disabilities Act.
2 We recommended the Malcom Randall VA Medical Center Director develop a formal plan to identify training needs of staff responsible for purchasing modular ramps and ensure staff are trained periodically and appropriately.
3 We recommended the Malcom Randall VA Medical Center Director update written procedures to reflect the requirement that staff ensure vendor compliance with Americans with Disabilities Act standards for installed modular ramps.
4 We recommend the Malcom Randall VA Medical Center Director formally require vendors to provide modular ramp measurements in bid submissions and post-installation photographs.
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| 13-02255-276 | Audit of VBA's Compensation and Pension Benefit Payments to Incarcerated Veterans | Audit | ||
1 We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and issue bills of collection to recover improper payments made to veterans while they were incarcerated.
Closure Date:
2 We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and take action to make appropriate benefits adjustments and issue bills of collection to recover improper payments for veterans currently incarcerated in Federal penal institutions.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits increase the priority placed on the Federal incarceration adjustment workload by using monthly data on Federal incarcerations to make appropriate and timely compensation and pension benefits adjustments.
Closure Date:
4 We recommended the Acting Under Secretary for Benefits monitor the terms of the current agreement with the Bureau of Prisons and take timely action to extend the agreement when appropriate.
Closure Date:
5 We recommended the Acting Under Secretary for Benefits increase the priority placed on state and local incarceration adjustment workload by initiating timely development action after receiving notifications of incarceration from the Social Security Administration.
Closure Date:
6 We recommended the Acting Under Secretary for Benefits increase priority of state and local incarceration adjustment workload by making timely incarceration adjustments and issue bills of collection to recover improper payments, as appropriate, after providing due process notification to veterans.
Closure Date:
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| 15-01296-203 | Community Based Outpatient Clinics Summary Report – Evaluation of Alcohol Use Disorder Care at Community Based Outpatient Clinics and Other Outpatient Clinics | 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 clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for 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 clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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| 16-00028-337 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Amarillo VA Health Care System, Amarillo, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the clinic manager ensures the risk of
infection is minimized when storing and disposing of medical waste at the Childress VA
Clinic.
Closure Date:
2 We recommended that the clinic manager ensures that exit
routes are unobstructed at the Childress VA Clinic.
Closure Date:
3 We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
Closure Date:
4 We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
Closure Date:
5 We recommended that staff at the Childress VA Clinic protect and secure patient-identifiable information.
Closure Date:
6 We recommended that the Childress VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
7 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
9 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
10 We recommended that clinicians consistently provide and document interventions for clinically significant abnormal laboratory results.
Closure Date:
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15168