Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00383-171 | Inspection of VA Regional Office New York, NY | Review | ||
1 We recommend the New York VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommend the New York VA Regional Office Director develop and implement a plan to review for accuracy the 320 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
3 We recommend the New York VA Regional Office Director develop and implement a plan to ensure staff comply with VBA and local second-signature requirements for traumatic brain injury claims
Closure Date:
4 We recommend that the New York VA Regional Office Director implement a plan to ensure staff comply with VARO policy requiring evaluation of higher-level special monthly compensation claims by staff assigned to the Special Operations team.
Closure Date:
5 We recommend the New York VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefit reductions to minimize improper payments to veterans.
Closure Date:
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| 13-03604-198 | Healthcare Inspection - Quality of Care and Staffing Concerns, Salem VA Medical Center, Salem, Virginia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director continue to monitor and address increases in post-operative infection rates and take appropriate corrective actions when indicated.
Closure Date:
2 We recommended that the Facility Director evaluate the admission process from the emergency department and monitor inter-unit transfer patterns, and take corrective actions as indicated.
Closure Date:
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| 12-03869-187 | Healthcare Inspection – Follow-Up of Mental Health Inpatient Unit and Outpatient Contract Programs, Atlanta VA Medical Center, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that a standardized and facility-wide repository be developed and implemented to monitor patients referred to community service boards.
Closure Date:
2 We recommended that the Facility Director strengthen processes to ensure that patients are tracked for follow-up beyond the first contracted mental health care appointment.
Closure Date:
3 We recommended that the Facility Director strengthen communication between the facility and the community service boards to better integrate and coordinate medical and mental health aspects of patient care.
Closure Date:
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| 14-00905-182 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Huntington VA Medical Center, Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes are strengthened to ensure women veterans can access gender-specific restrooms without entering public areas at the Prestonsburg CBOC.
Closure Date:
2 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 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:
4 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:
5 We recommended that staff consistently provide written medication information as required.
Closure Date:
6 We recommended that staff provide medication counseling/education as required.
VA OIG
Closure Date:
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| 14-01785-184 | Combined Assessment Program Summary Report – Evaluation of the Controlled Substances Inspection Program at Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that pharmacy physical security surveys are conducted and identified deficiencies are corrected and that compliance is monitored.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that quarterly controlled substances inspection trend reports of identified discrepancies, problematic trends, and potential areas for improvement are completed and provided to facility Directors.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that monthly inspections of all non-pharmacy controlled substances areas are conducted and that compliance is monitored.
Closure Date:
4 We recommended that the Under Secretary for Health ensures that VHA defines in policy acceptable reasons for missed controlled substances area inspections and provides guidance regarding Controlled Substances Coordinator performance of monthly inspections.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate 2 transfers of controlled substances from one storage area to another area, reconcile 1 day’s dispensing from the pharmacy to each automated unit, and verify electronic or written orders for 5 randomly selected dispensing activities.
Closure Date:
6 We recommended that the Under Secretary for Health, in
conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors perform quarterly physical counts of the emergency drug cache and monthly verifications of seals and that compliance is monitored.
Closure Date:
7 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate completion of all required drug destruction activities.
Closure Date:
8 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate accountability for all prescription pads stored in the pharmacy.
Closure Date:
9 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors conducting outpatient pharmacy inspections verify written prescriptions for 10 percent of (or a maximum of 50) schedule II drugs dispensed.
Closure Date:
10 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors receive annual training regarding problematic issues identified through external surveys and other quality control measures.
Closure Date:
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| 13-04324-170 | Inspection of the VA Regional Office, Reno, Nevada | Review | ||
1 We recommend the Reno VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
Closure Date:
2 We recommend the Reno VA Regional Office Director conduct a review of the 275 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommend the Reno VA Regional Office Director ensure required staff receive refresher training on how to identify insufficient traumatic brain injury medical examination reports and return them to the appropriate VA medical facilities for correction.
Closure Date:
4 We recommend the Reno VA Regional Office Director conduct training on the proper processing of special monthly compensation and ancillary benefits claims and implement a plan to assess the effectiveness of that training.
Closure Date:
5 We recommend the Reno VA Regional Office Director develop and implement a plan to ensure adequate and continuous oversight is provided for the timely completion of the annual Systematic Analyses of Operations schedule and the required 11 Systematic Analyses of Operations.
Closure Date:
6 We recommend the Reno VA Regional Office Director ensure that staff assigned to complete Systematic Analyses of Operations receive training on Veterans Benefits Administration policy regarding the purpose and requirements for completing Systematic Analyses of Operations.
Closure Date:
7 We recommend the Reno VA Regional Office Director amend the workload management plan to ensure oversight and prioritization of benefit reduction cases.
Closure Date:
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| 13-04592-179 | Healthcare Inspection – Alleged Preventive Maintenance Inspection Deficiencies, Northern Arizona VA Health Care System, Prescott, Arizona | Hotline Healthcare Inspection | ||
1 We recommended that the System Director initiate actions to address medical equipment with expired preventive maintenance inspections, that processes be strengthened to identify and track deficiencies to closure, and that compliance is monitored.
Closure Date:
2 We recommended that the System Director assess staffing in the Biomedical Engineering Department and take appropriate actions to meet the workload requirements.
Closure Date:
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| 13-04195-180 | Healthcare Inspection – Quality of Care Concerns, Hospice/Palliative Care Program, VA Western New York Healthcare System, Buffalo, New York | Hotline Healthcare Inspection | ||
1 13-04195-180
Closure Date:
2 13-04195-180
Closure Date:
| ||||
| 14-01686-185 | Follow-up Audit of VBA's 100 Percent Disability Evaluations | Audit | ||
1 We recommend the Under Secretary for Benefits ensure regional office staff take the appropriate action to review and process the records of all veterans with a temporary 100 percent disability evaluation within 180 days of the veteran’s inclusion on the TRAP report or the veteran’s scheduled exam.
2 We recommend the Under Secretary for Benefits ensure regional offices transfer from the Records Management Center all claims folders with temporary 100 percent disability evaluations to the regional office of jurisdiction.
Total Monetary Impact of All Recommendations
Open: $0
Closed: $222,600,000
Total: $222,600,000
| ||||
| 13-02129-177 | Audit of VBA’s Management of Concurrent VA and Military Drill Pay Compensation | Audit | ||
1 We recommended the Under Secretary for Benefits take measures to ensure drill pay offsets identified after fiscal year 2012 are timely processed.
Closure Date:
2 We recommended the Under Secretary for Benefits ensure fiscal years 2011 and 2012 drill pay offsets are processed.
Closure Date:
3 We recommended the Under Secretary for Benefits modify existing information technology systems to more effectively monitor, track, and report on drill pay offset activities.
Closure Date:
4 We recommended the Under Secretary for Benefits update the cost-benefit analysis regularly and use it to prioritize the processing of drill pay offsets.
Closure Date:
5 We recommended the Under Secretary for Benefits require Systematic Analysis of Operations be completed annually for drill pay matching activities.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $623,100,000
Total: $623,100,000
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15303