Recommendations
2102
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-01792-510 | Review of Alleged Mismanagement at the Health Eligibility Center | Audit | ||
1 We recommended the Under Secretary for Health provide guidance concerning how long applications may remain pending before reaching a final determination.
Closure Date:
2 We recommended the Under Secretary for Health assign an accountable official responsible to implement a plan to correct current data integrity issues in the Enrollment System.
Closure Date:
3 We recommended the Under Secretary for Health develop and execute a project management plan to ensure that Enrollment System data are fully evaluated and properly categorized.
Closure Date:
4 We recommended the Under Secretary for Health implement controls to ensure that future enrollment data are accurate and reliable before being entered in the Enrollment System.
Closure Date:
5 We recommended the Under Secretary for Health implement effective policies and procedures to accurately and timely identify deceased individuals with records in the Enrollment System and record their changed status in the system.
Closure Date:
6 We recommended the Under Secretary for Health establish appropriate policies and procedures to ensure Health Eligibility Center workload data are not deleted or changed without appropriate management review, approval, and audit trails.
Closure Date:
7 We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to Health Eligibility Center workload data are based upon specific job duties and the need to know.
Closure Date:
8 We recommended the Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the first three allegations, determine if administrative action should be taken against any senior Veterans Health Administration officials involved, and ensure that appropriate action is taken.
Closure Date:
9 We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
Closure Date:
10 We recommended that the Assistant Secretary for Information and Technology implement adequate security controls to enforce separation of duties and role-based access control for Workload Reporting and Productivity tool developers and administrators.
Closure Date:
11 We recommended that the Assistant Secretary for Information and Technology develop a monthly schedule to test whether Health Eligibility Center workload data are backed up properly and to provide the results of such testing to the Chief Business Office.
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12 We recommended the Assistant Secretary for Information and Technology confer with the Office of Human Resources and the Office of General Counsel to fully evaluate the implications of the lack of controls over the Workload Reporting and Productivity tool, determine if administrative action should be taken against any senior Office of Information Technology officials involved, and ensure that appropriate action is taken.
Closure Date:
13 We recommended the Under Secretary for Health perform monthly comparisons between Workload Reporting and Productivity reports and enrollment records to ensure the timely processing of applications and related documents.
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| 14-03531-402 | Healthcare Inspection – Alleged Delayed Mental Health Treatment and Other Care Issues, Kansas City VA Medical Center, Kansas City, MO | Hotline Healthcare Inspection | ||
1 We recommended that the Interim Under Secretary for Health review relevant inpatient program occupancy rates and wait times system-wide and determine whether additional guidance to facilities is needed to help ensure that the number of patients served through those programs is optimized.
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2 We recommended that the Facility Director ensure that processes be strengthened to ensure appropriate follow through on consults that are cancelled for administrative reasons.
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3 We recommended that the Facility Director ensure that Emergency Department providers fully evaluate patients with abnormal findings and make those evaluations readily accessible to other providers.
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4 We recommended that the Facility Director ensure that patients are evaluated and referred for treatment for certain health concerns if exhibited by patients presenting to the Emergency Department, when appropriate.
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| 15-00154-500 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Maine Healthcare System, Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
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2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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3 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
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5 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
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6 We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
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7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
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| 15-03063-511 | OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health ensure that the Veterans Health Administration further develops staffing models for critical need occupations.
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2 We recommended that the Under Secretary for Health review the data on regrettable losses in this report and Veterans Integrated Service Network Workforce Succession Strategic Plans and, if appropriate, consider implementing measures to reduce such losses.
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| 15-00158-499 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Durham VA Medical Center, Durham, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that review of the hazardous materials inventory occurs twice within a 12-month period at the Raleigh II CBOC.
2 We recommended that the staff at the Raleigh II CBOC participate in scheduled emergency management training and exercises.
3 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
4 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
5 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
6 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
7 We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by local policy.
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| 15-02397-494 | Review of VHA’s Alleged Mishandling of Ophthalmology Consults at the Oklahoma City VAMC | Audit | ||
1 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure patients affected by inappropriately discontinued ophthalmology consults receive the necessary eye care.
Closure Date:
2 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center initiate a review of discontinued teleretinal imaging consults and take action to provide eye care when necessary.
Closure Date:
3 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that guidance and responsibilities for making referrals on discontinued and cancelled consults is well-defined and formalized into policy.
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4 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that staff responsible for initiating and processing consults are properly trained on all applicable guidance and policies.
Closure Date:
5 We recommended the Interim Director of the Oklahoma City Veterans Affairs Medical Center ensure that all referring providers with electronic notifications responsibility receive adequate training.
Closure Date:
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| 15-00606-495 | Combined Assessment Program Review of the Battle Creek VA Medical Center, Battle Creek, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that credentialing and privileging folders do not contain non-allowed information.
2 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
3 We recommended that employees secure medication carts when not in use and that facility managers monitor compliance.
4 We recommended that facility managers maintain auditory privacy in all intake/exam areas and monitor compliance.
5 We recommended that facility managers ensure emergency crash carts receive checks with the frequency required by local policy and monitor compliance.
6 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
7 We recommended that facility managers revise the Radiology Service computed tomography quality assurance guideline to include radiologist review of appropriateness of computed tomography orders and specification of protocol prior to scans.
8 We recommended that facility managers comply with Veterans Health Administration directive requirements for exempted facilities, or if facility managers plan emergency intubation responses with onsite employees, they comply with Veterans Health Administration requirements for non-exempted facilities.
Closure Date:
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| 15-01381-437 | Inspection of VA Regional Office Phoenix, Arizona | Audit | ||
1 We recommended the Phoenix VA Regional Office Director conduct a review of the 325 temporary 100 percent disability evaluations remaining from their inspection universe as of December 17, 2014, and take appropriate action.
Closure Date:
2 We recommended the Phoenix VA Regional Office Director ensure frequent refresher training for processing higher levels of special monthly compensation and ancillary benefits claims.
Closure Date:
3 We recommended the Phoenix VA Regional Office Director implement a written plan to ensure oversight and prioritization of benefits reduction cases and related hearings.
Closure Date:
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| 15-00156-490 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of San Francisco VA Health Care System, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that hand hygiene compliance is monitored at the San Francisco VA Clinic and reported to the Infection Control Committee.
Closure Date:
2 We recommended that San Francisco VA Clinic staff store medical waste in a secure location.
Closure Date:
3 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
4 We recommended that clinic staff ensure that patients with excessive persistent alcohol use receive brief treatment within 2 weeks of the screening.
Closure Date:
5 We recommended that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
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| 13-03922-453 | Audit of Fiduciary Program Controls Addressing Beneficiary Fund Misuse | Audit | ||
1 We recommended the Under Secretary for Benefits revise policy to require timely removal of a fiduciary from all assigned beneficiaries when an individual case of misuse has been determined.
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2 We recommended the Under Secretary for Benefits retroactively establish debts for all fiduciaries who VBA determined misused beneficiary funds during calendar year 2013.
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3 We recommended the Under Secretary for Benefits revise policy to include clear timeliness standards from the time the hubs determine misuse occurred to the time Pension and Fiduciary Service completes the negligence determination.
Closure Date:
4 We recommended the Under Secretary for Benefits ensure the processing of all misuse actions are incorporated into quality reviews of Fiduciary Program operations.
Closure Date:
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15160