Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02465-47 | Audit of VHA’s Non-VA Medical Care Obligations | Audit | ||
1 We recommended that the Under Secretary for Health improve cost estimation tools to ensure adequate Non-VA Care cost estimates are produced consistently.
Closure Date:
2 We recommended that the Under Secretary for Health implement a mechanism to ensure that VA medical facilities perform ongoing reviews and adjust cost estimates for individual authorized services to better reflect actual costs.
Closure Date:
3 We recommended that the Under Secretary for Health update Fee Basis Claims System software to ensure inpatient authorizations can be periodically adjusted when the scope of patient care is fully known.
Closure Date:
4 We recommended that the Under Secretary for Health update Fee Basis Claims System software to allow the system to automatically deobligate unused funds when Non-VA Care staff indicate payments for the authorized services are complete.
Closure Date:
5 We recommended that the Under Secretary for Health implement a mechanism to monitor how effectively VA medical facilities are estimating Non-VA Care obligations.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $358,000,000
Total: $358,000,000
| ||||
| 15-05148-75 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers test the panic buttons regularly at the Victor J. Saracini VA Outpatient Clinic.
Closure Date:
2 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Victor J. Saracini VA Outpatient Clinic to the parent facility.
Closure Date:
3 We recommended that managers provide feminine hygiene disposal bins in women’s public restrooms at the Victor J. Saracini VA Outpatient Clinic.
Closure Date:
4 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
| ||||
| 15-05158-74 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Edward Hines, Jr. VA Hospital, Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff at the Joliet VA Clinic position monitors or use privacy screens to prevent viewing of personally identifiable information on computers in public areas.
2 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
3 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive PTSD screens.
| ||||
| 14-03981-54 | Follow Up Review on the Mismanagement of Informal Claims Processing at the VA Regional Office Oakland, California | Audit | ||
1 We recommended the Oakland VA Regional Office Director provide training to the Quality Review Team, Decision Review Officers and Rating Veterans Service Representatives on proper informal claims processing procedures for communications received from service organizations, attorneys, or agents.
Closure Date:
2 We recommended the VA Regional Office Oakland Director conduct a complete review of the additional list of 690 claims that may be informal claims, take appropriate actions, and provide certification of completion of the review to the Office of Inspector General.
Closure Date:
3 We recommended the VA Regional Office Oakland Director conduct another review of the remaining 1,248 informal claims and provide certification of completion of the review to the Office of Inspector General.
Closure Date:
| ||||
| 14-04302-12 | Review of Alleged Supervisory Influence To Expedite a Friend’s Disability Claim at VA Regional Office New York, New York | Audit | ||
1 We recommended the Director of the New York VA Regional Office take actions, as appropriate, to ensure similar incidents involving expediting friends’ disability claims do not occur in the future.
Closure Date:
2 We recommended the Director of the New York VA Regional Office develop and implement a mechanism to ensure staff have a venue for reporting violations of ethical standards of conduct in the future, should any occur.
Closure Date:
| ||||
| 14-05075-447 | Healthcare Inspection – Patient Care Deficiencies and Mental Health Therapy Availability, Overton Brooks VA Medical Center, Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure patients are notified and re-assigned timely when their mental health providers leave the facility.
Closure Date:
| ||||
| 14-04816-72 | Review of Alleged Problems With VBA’s Veterans Benefits Management System and Claims Processing | Audit | ||
1 We recommended the Under Secretary for Benefits ensure that the St. Petersburg VA Regional Office is consistently organizing and mailing hard copy veteran material to contractor scanning facilities and hold the Regional Office Director accountable for compliance.
Closure Date:
2 We recommended the Under Secretary for Benefits initiate onsite reviews of the CACI contractor scanning facilities to ensure the timely processing and the proper storage of VA sensitive information at those facilities.
Closure Date:
| ||||
| 15-00827-68 | Healthcare Inspection – Poor Follow-Up Care and Incomplete Assessment of Disability, VA San Diego Healthcare System San Diego, California | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health ensure that Compensation & Pension examiners document that patients with new diagnoses are counseled on the need for follow up care and provided assistance in obtaining VA care.
Closure Date:
2 We recommended that the Under Secretary for Health develop guidance on what clinical information from secure messaging and My HealtheVet must be documented in the EHR.
Closure Date:
3 We recommended that the System Director implement processes to ensure that providers adhere to the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, including follow up assessment at appropriate intervals, when treating patients with chronic opioid therapy.
Closure Date:
4 We recommended that the System Director confer with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient.
Closure Date:
5 We recommended that the VA Regional Office San Diego Director review a sample of the specific rater’s work and determine whether failure to obtain relevant service treatment records is a systemic issue with this rater when making compensation claim decisions.
Closure Date:
| ||||
| 15-00268-66 | Healthcare Inspection – Eye Care Concerns, Eastern Kansas Health Care System, Topeka and Leavenworth, Kansas | Hotline Healthcare Inspection | ||
1 We recommended that the Eastern Kansas Health Care System Director ensure all system staff use only approved wait lists for scheduling cataract surgeries as required by Veterans Health Administration Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, June 2010.
2 We recommended that the Eastern Kansas Health Care System Director ensure that providers use the consultation package in the Computerized Patient Records System for all eye care referrals as required by VHA Handbook 1121.01, VHA Eye Care, March 10, 2011.
3 We recommended that the Eastern Kansas Health Care System Director take actions to increase ophthalmologists’ productivity.
4 We recommended that the Eastern Kansas Health Care System Director explore and implement measures to improve communication, interpersonal dynamics, and operations within and between both Eye Clinics.
| ||||
| 15-04699-65 | Combined Assessment Program Review of the Royal C. Johnson Veterans Memorial Medical Center, Sioux Falls, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
2 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
| ||||
15303