Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02396-212 | Healthcare Inspection – Alleged Medication Cart Deficiencies and Unsafe Medication Administration Practices, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that an adequate number of fully functioning medication carts are available for nurses to administer medications safely and on time.
Closure Date:
2 We recommended that the Facility Director ensure that nurses document the reasons for late medication administration.
Closure Date:
3 We recommended that the Veterans Integrated Service Network Director enhance processes to improve purchasing and contracting efficiency for patient care equipment and items.
Closure Date:
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| 14-00918-204 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Grand Junction VA Medical Center, Grand Junction, Colorado | Comprehensive Healthcare Inspection Program | ||
1 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:
2 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:
3 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
4 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Closure Date:
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| 13-02892-217 | Healthcare Inspection – Alleged Mismanagement in the Cardiac Catheterization Laboratory, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that nurse staffing is appropriate for the volume and types of procedures performed in the cardiac catheterization laboratory and that the requisite nurse competencies are maintained.
2 We recommended that the System Director ensure that the policies and procedures regarding the rapid response team, code blue team, and Anesthesia Services are updated as needed to reflect desired practices for managing cardiac catheterization laboratory emergencies.
3 We recommended that the System Director ensure that the staff receive training on updated policies and procedures regarding the rapid response, code blue team and Anesthesia Services.
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| 13-03468-203 | Audit of NCA's Rural Veterans Burial Initiative | Audit | ||
1 We recommended the Under Secretary for Memorial Affairs establish a methodology to identify the number and percentage of served and unserved rural veterans throughout the Nation.
Closure Date:
2 We recommended the Under Secretary for Memorial Affairs publish a national map showing the areas and number of served and unserved rural veterans.
Closure Date:
3 We recommended the Under Secretary for Memorial Affairs establish performance goals for the percentage of rural and urban veterans served.
Closure Date:
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| 13-03699-209 | Review of VBA’s Special Initiative To Process Rating Claims Pending Over 2 Years | Audit | ||
1 We recommended the Under Secretary for Benefits implement a plan toidentify all provisionally-rated claims and ensure the proper controls areentered in the electronic system to track, manage, and complete them.
Closure Date:
2 We recommended the Under Secretary for Benefits implement actions toinclude provisionally-rated claims in the rating inventory and correct theaging of provisional claims in pending workload statistics.
Closure Date:
3 We recommended the Under Secretary for Benefits implement a plan toexpedite final decisions on all issues in provisionally-rated claims.
Closure Date:
4 We recommend the Under Secretary for Benefits implement actions to complete quality reviews to ensure accuracy of all provisionally rated claims processed under this special initiative.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $40,400,000
Total: $40,400,000
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| 14-03644-225 | Review of Alleged Mail Mismanagement at VBA’s Baltimore VA Regional Office | Audit | ||
1 We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff analyze and take appropriate actions to properly control the approximately 9,500 documents and 80 claims folders referenced in this report.
Closure Date:
2 We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff receive refresher training on proper mail handling procedures.
Closure Date:
3 We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office supervisory staff receive refresher workload management training.
Closure Date:
4 We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff conduct quarterly desk audits as required.
Closure Date:
5 We recommend the Under Secretary for Benefits implement a plan to ensure Baltimore VA Regional Office staff assess the impact that mismanaged mail and claims processing actions had on benefits delivery and provide that information for our review.
Closure Date:
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| 13-01452-214 | Audit of Post-9/11 G.I. Bill Monthly Housing Allowance and Book Stipend Payments | Audit | ||
1 We recommended the Under Secretary for Benefits ensure the Post-9/11 G.I. Bill application provides veterans with clear, adequate information on educational benefits and the requirement to relinquish other education benefits before submission.
Closure Date:
2 We recommended the Under Secretary for Benefits determine and establish a timeliness standard for the submission of initial enrollment certifications and a mechanism to monitor school certifying officials’ compliance with the submission of initial enrollment certifications and changes.
Closure Date:
3 We recommended the Under Secretary for Benefits reinforce the need for school certifying officials to complete available Veterans Benefit Administration online training on the timely and accurate reporting of enrollments and changes through the Veterans Affairs Online Certification Enrollment system.
Closure Date:
4 We recommended the Under Secretary for Benefits ensure Education Service establishes a monitoring mechanism to include reviews of enrollment changes in its quarterly quality reviews of Regional Processing Office claims.
Closure Date:
5 We recommended the Under Secretary for Benefits ensure Long Term Solution calculations for book stipends align with the regulatory requirements established for students who are enrolled at 50 percent or less.
Closure Date:
6 We recommended the Under Secretary for Benefits ensure Veterans Benefit Administration Regional Processing Office staff regularly update school information in the Web Enabled Approval Management System and include accurate full-time equivalency information in the schools’ profiles.
Closure Date:
7 We recommended the Under Secretary for Benefits reconcile Education Service procedures and Federal regulations and decide whether or not book stipends will be recovered from students who withdraw from courses without mitigating circumstances.
Closure Date:
8 We recommended the Under Secretary for Benefits ensure the Veterans Benefits Administration collects outstanding improper payments identified by this audit as defined by the Improper Payments Elimination and Recovery Act.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $205,000,000
Total: $205,000,000
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| 14-01053-172 | Inspection of the VA Regional Office New Orleans, LA | Review | ||
1 We recommend the New Orleans VA Regional Office Director conduct a review of the 329 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommend the New Orleans VA Regional Office Director implement a plan to assess the effectiveness of their recent training on processing traumatic brain injury claims and special monthly compensation benefits.
Closure Date:
3 We recommend the New Orleans VA Regional Office Director implement a plan to emphasize that rating staff address all ancillary benefits, even if not expressly claimed, to ensure veterans receive maximum entitlement to benefits.
Closure Date:
4 We recommend the New Orleans VA Regional Office Director implement a plan to ensure Systematic Analyses of Operations contain all required elements including specific timeframes for completion of recommendations.
Closure Date:
5 We recommend the New Orleans VA Regional Office Director ensure that staff receive training on VBA policy regarding the purpose and requirements for completing Systematic Analyses of Operations.
Closure Date:
6 We recommend the New Orleans VA Regional Office Director develop and implement a plan to ensure staff prioritize processing of benefit reductions at the expiration of due process as required.
Closure Date:
7 We recommend the New Orleans VA Regional Office Director provide training on the proper procedures for benefit reductions and implement a plan to assess the effectiveness of that training.
Closure Date:
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| 14-00915-206 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are improved to ensure hazardous materials are inventoried and tracked at the Parsons CBOC.
Closure Date:
2 We recommended that a panic alarm system is installed at the Parsons CBOC.
Closure Date:
3 We recommended that fire drills are performed every 12 months at the Parsons CBOC.
Closure Date:
4 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Parsons CBOC to the parent facility or contracted processing facility.
Closure Date:
5 We recommended that the door to the examination room designated for women veterans is equipped with an electronic or manual lock at the Parsons CBOC.
Closure Date:
6 We recommended processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Parsons CBOC.
Closure Date:
7 We recommended that all identified environment of care deficiencies at the Parsons CBOC are reported to and tracked by the parent facility¿s Environment of Care Committee until resolution.
Closure Date:
8 We recommended that the parent facility include staff at the Parsons CBOC in required education, training, planning, and participation in annual disaster exercises.
Closure Date:
9 We recommended that the parent facility document Emergency Management Preparedness-specific training completed for the Parsons CBOC clinical providers.
Closure Date:
10 We recommended that the parent facility's Emergency Management Committee evaluate the Parsons CBOC's emergency preparedness activities, participation in annual disaster exercises, and staff training/education relating to emergency preparedness requirements.
Closure Date:
11 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
12 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:
13 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:
14 We recommended that staff consistently provide written medication information that includes the fluoroquinolone.
Closure Date:
15 We recommended that staff provide medication counseling/education as required.
Closure Date:
16 We recommended that staff document the evaluation of patient's level of understanding for the medication education.
Closure Date:
17 We recommended that the chief of staff consistently ensures that all Designated Women's Health Providers are designated with the women's health indicator in the Primary Care Management Module.
Closure Date:
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| 11-00323-169 | Follow-Up Audit of VHA's Workers' Compensation Case Management | Audit | ||
1 We recommended the Acting Under Secretary for Health establish Workers’ Compensation Program case file documentation standards so that specialists ensure case files are complete (repeat recommendation from the 2004 and 2011 VA Office of Inspector General audit reports).
Closure Date:
2 We recommended the Acting Under Secretary for Health establish a directive mandating Workers’ Compensation Program specialists implement the workers’ compensation guidebook to ensure specialists question the validity of claims lacking adequate supporting evidence.
Closure Date:
3 We recommended the Acting Under Secretary for Health establish a structure with a clear chain of command to ensure workers’ compensation compliance with case management requirements, oversight, and policy enforcement.
Closure Date:
4 We recommended the Acting Under Secretary for Health implement controls to ensure workers’ compensation staff who are responsible for case management make job offers to medically able employees (repeat recommendation from the 2004 and 2011 VA Office of Inspector General audit reports).
Closure Date:
5 We recommended the Acting Under Secretary for Health ensure medical center directors assign adequate staff to manage Workers’ Compensation Program cases (repeat recommendation from the 2004 and 2011 VA Office of Inspector General audit reports).
Closure Date:
6 We recommended the Acting Under Secretary for Health develop and implement fraud identification and referral procedures (repeat recommendation from the 2011 VA Office of Inspector General audit report).
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $95,100,000
Total: $95,100,000
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15303