Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-01545-11 | Review of Alleged Mismanagement of VA's Office of Public and Intergovernmental Affairs Outreach Contracts | Audit | ||
1 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs limit future use of time and materials contracts to those instances where the extent or duration of the work cannot be anticipated with any reasonable degree of confidence.
2 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that significant new contract requirements are solicited in lieu of merely modifying existing contracts to meet new needs.
3 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that contractor billings are approved based on sufficient documentation to demonstrate that contractors are meeting performance-based requirements.
4 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs implement improved oversight of contractor activities to ensure they are appropriate to meet contract terms and do not include inherently Governmental functions.
5 We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs develop and implement program performance metrics to determine whether outreach and awareness campaigns are improving veterans’ awareness of and access to VA services and benefits.
Total Monetary Impact of All Recommendations
Open: $0
Closed: $5,000,000
Total: $5,000,000
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| 12-02576-30 | Audit of VHA's Support Service Contracts | Audit | ||
1 We recommended the Interim Under Secretary for Health implement a quality assurance program that provides sufficient oversight to ensure that contracting issues are corrected by the responsible contracting office.
Closure Date:
2 We recommended the Interim Under Secretary for Health implement a mechanism to facilitate and ensure contracting officers’ performance can be objectively evaluated against their performance standards.
Closure Date:
3 We recommended the Interim Under Secretary for Health monitor contracting officer performance deficiencies and ensure training is provided to correct identified deficiencies.
Closure Date:
4 We recommended the Interim Under Secretary for Health ensure contracting staff complete Integrated Oversight Process reviews in accordance with established policies and contracting officers’ performance standards.
Closure Date:
5 We recommended the Interim Under Secretary for Health revise Integrated Oversight Process review procedures to include a review to ensure Advisory and Assistance services are identified and approved.
Closure Date:
6 We recommended the Interim Under Secretary for Health ensure that contracting officers delegate in writing contracting officers’ representatives requirements and authorities to monitor contracts, as required by Federal and VA acquisition policy and contracting officers’ performance standards.
Closure Date:
7 We recommended the Interim Under Secretary for Health ensure that contracting officers conduct and document quarterly meetings with contracting officers’ representatives as required by VA acquisition policy.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $795,000,000
Total: $795,000,000
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| 14-02083-24 | Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that patient learning assessments are documented within 24 hours of admission and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that providers complete and document patient discharge progress notes or discharge instructions and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that clinicians provide printed stroke education to patients upon discharge and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that compliance be monitored.
Closure Date:
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| 14-02101-09 | Inspection of VA Regional Office Huntington, West Virginia | Review | ||
1 The Huntington VA Regional Office Director develop and implement a plan to review for accuracy the 138 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
2 The Huntington VA Regional Office Director develop and implement a plan to ensure staff receive refresher training on identifying and returning insufficient medical examination reports related to traumatic brain injury claims to medical facilities for correction.
3 The Huntington VA Regional Office Director develop and implement a plan to ensure staff comply with the Veterans Benefits Administration’s second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing these claims to identify local training needs.
4 The Huntington VA regional Office Director develops and implements a plan to ensure staff complies with local second-signature requirements for processing special monthly compensation.
5 The Huntington VA Regional Office Director ensure claims processing staff receive refresher training on processing special monthly compensation and ancillary benefits.
6 The Huntington VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans
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| 14-01519-40 | Healthcare Inspection – Quality and Coordination of Care Concerns at Three Veterans Integrated Service Network 11 Facilities | Hotline Healthcare Inspection | ||
1 We recommended that the Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible institutional disclosure.
Closure Date:
2 We recommended that the Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
Closure Date:
3 We recommended the Network Director conduct a thorough review of the Northern Indiana Health Care System Mental Health Service’s processes and leadership.
Closure Date:
4 We recommended that the Network Director ensure providers’ electronic health record documentation is consistent with VHA Handbook 1907.01, Health Information Management and Health Records, especially in regards to discharge instructions and summaries, patient problem lists, and critical telephone and fax communications, as discussed in this report.
Closure Date:
5 We recommended that the Network Director ensure that Northern Indiana Health Care System Non-VA Care Coordination staff case manage patients consistent with their current functional statements or that the role of Non-VA Care Coordination staff be reassessed and functional statements changed to reflect tasks actually performed by the Non-VA Care Coordination staff.
Closure Date:
6 We recommended that the Network Director ensure that all Northern Indiana Health Care System providers receive ongoing professional practice evaluations consistent with VHA Directive 1100.19, Credentialing and Privileging.
Closure Date:
7 We recommended that the Network Director ensure that responsible clinical staff review the patient’s electronic health record and initiate appropriate follow-up action consistent with VHA Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, when a patient is a “no show.”
Closure Date:
8 We recommended that the Network Director ensure that the Northern Indiana Health Care System Director develop guidelines for documenting and responding to secure messages.
Closure Date:
9 We recommended that the Network Director ensure that Northern Indiana Health Care System mental health patients be assigned a Mental Health Treatment Coordinator and that a process is in place to reassign coordinators in the event of staff departure consistent with the Deputy Undersecretary for Health for Operations and Management’s “Assignment of the Mental Health Treatment Coordinator” and local policy requirements.
Closure Date:
10 We recommended that the Network Director ensure that Northern Indiana Health Care System Community Based Outpatient Clinic mental health services are provided consistent with VHA Directive 1160.01, Uniform Mental Health Services in VA Medical Centers and Clinics.
Closure Date:
11 We recommended that the Network Director ensure processes are in place at the Northern Indiana Health Care System to ensure continuity of mental health care in the event of staff departure and/or reassignment.
Closure Date:
12 We recommended that the Network Director ensure Northern Indiana Health Care System telephone triage, suicide prevention program, and emergency department staff receive training regarding expected psychiatric emergency response.
Closure Date:
13 We recommended that the Network Director ensure Northern Indiana Health Care System providers implement stepped consultative care and integrate behavioral health with the primary care of chronic pain consistent with VHA Directive 2009-053, Pain Management.
Closure Date:
14 We recommended that the Network Director ensure that Richard L. Roudebush VA Medical Center Clinical Application Coordinators remove Computerized Patient Record System consult order templates from facility ordering systems when a consult service is no longer offered.
Closure Date:
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| 13-03221-08 | Inspection of VA Regional Office Providence, Rhode Island | Review | ||
1 We recommended the Providence VA Regional Office Director conduct a review of the 70 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommended the Providence VA Regional Office Director provide oversight to ensure staff follows Veterans Benefits Administration guidance related to processing reminder notifications for medical reexaminations.
Closure Date:
3 We recommended the Providence VA Regional Office Director ensure staff receive refresher training on proper evaluation of traumatic brain injury and special monthly compensation and ancillary benefits claims and implement plans to ensure the effectiveness of that training.
Closure Date:
4 We recommended the Providence VA Regional Office Director develop and implement a plan to ensure timely completion of Systematic Analyses of Operations.
Closure Date:
5 We recommended the Providence VA Regional Office Director amend, implement, and monitor the local Workload Management Plan to ensure staff takes timely action on claims requiring rating decisions for reduction of benefits.
Closure Date:
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| 14-02084-16 | Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that completed actions from peer reviews are consistently documented in Peer Review Committee meeting minutes.
Closure Date:
2 We recommended that processes be strengthened to ensure that Focused Professional Practice Evaluation results for newly hired licensed independent practitioners are consistently reported to the Medical Executive Committee.
Closure Date:
3 We recommended that processes be strengthened to ensure that continuing stay reviews are consistently performed on at least 75 percent of patients in acute beds.
Closure Date:
4 We recommended that the Surgical Work Group meet monthly.
Closure Date:
5 We recommended that processes be strengthened to ensure that the critical incident tracking and notification system’s recipient list is current.
Closure Date:
6 We recommended that processes be strengthened to ensure that the Blood Utilization Committee representative from Anesthesia Service consistently attends meetings.
Closure Date:
7 We recommended that processes be strengthened to ensure that Environment of Care-Safety Committee meeting minutes reflect sufficient discussion of deficiencies, corrective actions taken, and tracking of actions to closure.
Closure Date:
8 We recommended that processes be strengthened to ensure that the negative pressure control systems in the dialysis isolation rooms are functional and that the dialysis unit water treatment, sterile supply, clean utility, and soiled utility room doors are secured at all times and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that equipment is not stored in the restraint room on the locked mental health unit and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that documentation of pachymetry probe reprocessing in the eye clinic is in accordance with the manufacturer’s instructions and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that clinicians screen patients for difficulty swallowing prior to oral intake.
Closure Date:
13 We recommended that processes be strengthened to ensure that staff complete and document restorative nursing services according to clinician orders and/or residents’ care plans, document resident progress towards restorative nursing goals, and document reasons why care planned restorative nursing services were not provided or were discontinued and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients’ electronic health records of all potential contraindications prior to the scan and that compliance be monitored.
Closure Date:
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| 14-00937-31 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at VA Northern California Health Care System, Mather, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are improved to ensure compliance with requirements for hazardous materials, including tracking of hazardous materials inventories at the Martinez CBOC, reviewing these inventories twice within a 12-month period at the Martinez and Redding CBOCs, and training Martinez CBOC staff to ensure access to the electronic version of the material safety data sheets.
Closure Date:
2 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Fairfield and Martinez CBOCs to the parent facility or contracted processing facility, by securing patient data in the Health Education Room, and through the use of privacy screens on computer monitors at the Martinez Primary Care check-in desk.
Closure Date:
3 We recommended that the parent facility’s Emergency Management Committee includes the CBOC in required education, training, planning, and participation leading up to the annual disaster exercise and evaluates the Fairfield, Martinez, and Redding CBOCs’ emergency preparedness activities and participation in annual disaster exercises.
Closure Date:
4 We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
5 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
6 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
8 We recommended that staff provide and document medication counseling/education as required.
Closure Date:
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| 14-02577-07 | Inspection of VA Regional Office Buffalo, New York | Review | ||
1 We recommended the Buffalo VA Regional Office Director develop and implement a plan to review the 206 temporary 100 percent disability evaluation claims remaining from our inspection universe and take appropriate actions.
Closure Date:
2 We recommended the Buffalo VA Regional Office Director develop and implement a plan to monitor the effectiveness of training on higher-level Special Monthly Compensation and Ancillary Benefits.
Closure Date:
3 We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure Systematic Analysis of Operations contain thorough analyses, use appropriate data, and include all recommendations needed, along with time frames for implementation.
Closure Date:
4 We recommended the Buffalo VA Regional Office Director develop and implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 14-00939-27 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Pembroke Pines CBOC location is clearly identified from the street as a VHA CBOC.
Closure Date:
2 We recommended that the main entrance and restroom doors at the Key Largo CBOC are accessible per Americans with Disabilities Act guidelines.
Closure Date:
3 We recommended that signage is installed at the Pembroke Pines CBOC to clearly identify the location of fire extinguishers.
Closure Date:
4 We recommended that exit signs are visible from all directions at the Key Largo CBOC.
Closure Date:
5 We recommended that personally identifiable information is protected by securing laboratory specimens during transport from the Key Largo and Pembroke Pines CBOCs to the parent facility.
Closure Date:
6 We recommended that clinic staff provide adequate privacy for women veterans at the Key Largo and Pembroke Pines CBOCs.
Closure Date:
7 We recommended that access to the information technology server closet at the Key Largo CBOC is documented.
Closure Date:
8 We recommended that CBOC/Primary Care Clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
9 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
10 We recommended that staff consistently document and provide written medication information that includes the fluoroquinolones.
Closure Date:
11 We recommended that staff consistently document and provide medication counseling/education as required.
Closure Date:
12 We recommended that staff consistently document the evaluation of patient's level of understanding for the medication education.
Closure Date:
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15303