Recommendations
2132
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-00644-231 | Review of VA's Acquisitions Supporting the Veteran Employment Services Office | Audit | ||
1 We recommend the Acting Assistant Secretary for Human Resources and Administration improve the development and management of ADVANCE-funded acquisitions by strengthening the Strategic Management Group's process to fully assess program offices' procurement requests against VA's existing internal capacities.
Closure Date:
2 We recommend the Acting Assistant Secretary for Human Resources and Administration take immediate action to assess veteran demand for call center services and modify the terms of its interagency agreement with the Office of Personnel Management to reflect anappropriate level of call center operations and related costs, including staffing resources.
Closure Date:
3 We recommend the Acting Assistant Secretary for Human Resources and Administration modify the Veteran Employment Services Office's interagency agreement with the Office of Personnel Management to require routine data reports on call centers' performance that include call volume, length of calls, blocked calls, wait times, and the overall accuracy of information provided to callers.
Closure Date:
4 We recommend the Acting Assistant Secretary for Human Resources and Administration develop a process to independently assess the performance of the Veteran Employment Services Office's employment call centers by establishing metrics such as call volume, call wait times, hang-ups, and accuracy of information.
Closure Date:
5 We recommend the Acting Assistant Secretary for Human Resources and Administration develop policy that prohibits the approval of modifications to interagency agreement terms that combine the costs and terms of distinct deliverables into one deliverable.
Closure Date:
6 We recommend the Acting Assistant Secretary for Human Resources and Administration develop requirements to test and assess functions to be contracted to determine if these functions are inherently governmental as part of the acquisition planning process for all future contracts awarded to support the Veteran Employment Services Office's operations and initiatives.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $17,500,000
Total: $17,500,000
| ||||
| 13-00026-223 | Community Based Outpatient Clinic Reviews at VA Pacific Islands Health Care System, Honolulu, HI | Comprehensive Healthcare Inspection Program | ||
1 We recommend that VISN and Facility Directors, in conjunction with the respective CBOC managers, should take appropriate actions to ensure that clinicians screen patients for tetanus vaccinations.
Closure Date:
2 We recommend that VISN and Facility Directors, in conjunction with the respective CBOC managers, should take appropriate actions to ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommend that VISN and Facility Directors, in conjunction with the respective CBOC managers, should take appropriate actions to ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
4 We recommend that VISN and Facility Directors, in conjunction with the respective CBOC managers, should take appropriate actions to ensure that a hazard assessment is conducted at the Hilo CBOC to determine if an emergency eyewash station is warranted.
Closure Date:
| ||||
| 13-00367-226 | Inspection of VA Regional Office Houston, Texas | Review | ||
1 We recommend the Houston VA Regional Office Director implement a plan to ensure staff timely follow Veterans Benefits Administration policy to reduce temporary 100 percent disability evaluations when required.
Closure Date:
2 We recommend the Houston VA Regional Office Director develop and implement a plan to follow up on hearing requests associated with proposed reductions.
Closure Date:
3 We recommend the Houston VA Regional Office Director conduct a review of the 689 temporary 100 percent disability evaluations remaining from the data we used to perform the inspection and take appropriate action.
Closure Date:
4 We recommend the Houston VA Regional Office Director implement a plan to assess the effectiveness of training and provide refresher training on the proper processing of traumatic brain injury claims.
Closure Date:
5 We recommend the Houston VA Regional Office Director develop and implement a plan to ensure accurate second-signature reviews of traumatic brain injury claims.
Closure Date:
6 We recommend the Houston VA Regional Office Director ensure Veterans Service Center management amends the Systematic Analyses of Operations checklist to address all elements currently required by Veterans Benefits Administration policy and provide refresher training.
Closure Date:
| ||||
| 13-00890-220 | Combined Assessment Program Review of the Alaska VA Healthcare System, Anchorage, Alaska | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are consistently reported to the MEC.
Closure Date:
3 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
Closure Date:
4 We recommended that processes be strengthened to ensure that quarterly trend reports summarize any discrepancies and problematic trends and identify potential areas for improvement.
Closure Date:
5 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and refresher training regarding problematic issues identified through external survey findings and other quality control measures.
Closure Date:
6 We recommended that processes be strengthened to ensure that local policy related to the return of Green Sheets to the pharmacy is adhered to and that all elements required for the processing of prescriptions are present.
Closure Date:
7 We recommended that processes be strengthened to ensure that documentation of CS inspector orientation, training, annual updates, and annual competency assessments are maintained.
Closure Date:
8 We recommended that processes be strengthened to ensure that CS inspectors initial and date CS Inspecting Official Checklists, VA CS forms, and pharmacy activity logs.
Closure Date:
9 We recommended that a process be established to track HPC consults that are not acted upon within 7 days of the request.
Closure Date:
10 We recommended that processes be strengthened to ensure that the COS reviews HRCP activities in a timely manner.
Closure Date:
11 We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
Closure Date:
| ||||
| 13-00274-224 | Combined Assessment Program Review of the VA Pacific Islands Health Care System, Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the PSB.
Closure Date:
2 We recommended that processes be strengthened to ensure that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
4 We recommended that nursing managers monitor the staffing methodology that was implemented in November 2012.
Closure Date:
| ||||
| 13-00894-216 | Combined Assessment Program Review of the VA Manila Outpatient Clinic, Manila, Philippines | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility initiate monitoring of the copy and paste function.
Closure Date:
2 We recommended that the Peer Review Committee meets at least quarterly or that a notation be made if there are no cases to discuss for the quarter.
Closure Date:
3 We recommended that processes be strengthened to ensure that EOC and Infection Prevention/Control Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
Closure Date:
4 We recommended that processes be strengthened to ensure that infection prevention risk assessments are conducted.
Closure Date:
5 We recommended that processes be strengthened to ensure that fire extinguisher inspections are conducted monthly and documented.
Closure Date:
6 We recommended that a process be implemented to ensure that laboratory specimens are transported in a secure manner.
Closure Date:
7 We recommended that processes be strengthened to ensure that CS inspectors verify hard copy prescriptions for 10 percent of the schedule II drugs dispensed in the outpatient pharmacy and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that patients at high risk for suicide and/or their families receive a copy of the safety plan.
Closure Date:
9 We recommended that processes be strengthened to ensure that clinicians administer tetanus vaccinations when indicated.
Closure Date:
10 We recommended that the facility develop and implement a policy related to screening and referral for at-risk diabetic patients.
Closure Date:
11 We recommended that processes be strengthened to ensure that diabetic patients receive annual risk assessments with risk level scores and that the assessments are documented in the EHRs.
Closure Date:
12 We recommended that processes be strengthened to ensure that diabetic patients at moderate or high risk receive foot exams at each routine primary care visit.
Closure Date:
13 We recommended that processes be strengthened to ensure that patients are consistently notified of critical/abnormal test results and that notification is documented in the EHRs.
Closure Date:
14 We recommended that processes be strengthened to ensure that debriefings occur after incidents of disruptive or violent behavior.
Closure Date:
| ||||
| 13-00886-210 | Combined Assessment Program Review of the VA New Jersey Health Care System, East Orange, New Jersey | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
2 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
3 We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
4 We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes and that code sheets are scanned into the EHRs.
Closure Date:
5 We recommended that processes be strengthened to ensure that clean and dirty items are stored separately.
Closure Date:
6 We recommended that processes be strengthened to ensure that sensitive patient information is secured on computer screens in the ED.
Closure Date:
7 We recommended that processes be strengthened to ensure that medical equipment in the ED is terminally cleaned after patient discharge.
Closure Date:
8 We recommended that processes be strengthened to ensure that supplies and equipment in the East Orange PT clinic are properly stored.
Closure Date:
9 We recommended that facility policy be amended to address that the CS Coordinator PD or functional statement must include CS inspection and coordination, to include that the CS Coordinator must have complete understanding of CS policies and VHA inspection process, and to include requirements for new CS inspector orientation and annual training thereafter.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors receive annual updates and/or refresher training.
Closure Date:
11 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
12 We recommended that processes be strengthened to ensure that the Chief of Staff reviews Home Respiratory Care Program activities at least quarterly.
Closure Date:
13 We recommended that processes be strengthened to ensure that contracts for oxygen delivery contain educational information on the hazards of smoking while oxygen is in use.
Closure Date:
14 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
15 We recommended that processes be strengthened to ensure that home oxygen program patients deemed to be high risk have fire risk assessments completed and that 3-month follow-up evaluations are completed for all home oxygen program patients.
Closure Date:
16 We recommended that unit 9A's expert panel include all required members.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensure that all required staff are facility expert panel members.
Closure Date:
18 We recommended that managers initiate protected peer review for the identified patient and complete any recommended review actions.
Closure Date:
| ||||
| 13-00026-213 | Community Based Outpatient Clinic Reviews at Central Texas Veterans Health Care System, Temple, TX, and VA Texas Valley Coastal Bend Health Care System, Harlingen, TX | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
2 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the defined timeframe and that notification is documented in the EHR.
3 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
4 We recommended that managers ensure that clinicians document all required tetanus and pneumococcal vaccination administration elements and that compliance is monitored.
5 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
6 We recommended that managers ensure that clinicians document all required pneumococcal vaccination administration elements and that compliance is monitored.
7 We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Cedar Park CBOC.
8 We recommended that the service chief’s documentation in VetPro reflects documents reviewed and the rationale for re-privileging at the Corpus Christi Satellite, Harlingen OPC, and Laredo CBOC.
9 We recommended that signage is installed at the Corpus Christi Satellite, Harlingen OPC, and McAllen Satellite to clearly identify the location of fire extinguishers.
10 We recommended that a panic alarm system is installed at the Laredo CBOC.
11 We recommended that medications are reviewed for need, secured, and only accessible by those individuals who either dispen
12 We recommended that the placement of the telecommunications network beevaluated and that appropriate safety measures are implemented at theCorpus Christi Satellite.
| ||||
| 13-00432-217 | Combined Assessment Program Review of the Spokane VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are consistently completed and reported to the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that the CACC reviews each code episode.
Closure Date:
3 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person and a dedicated psychologist or other mental health provider.
Closure Date:
4 We recommended that the PCCT provide end-of-life training on a regular basis.
Closure Date:
5 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
6 We recommended that processes be strengthened to ensure that HPC consults are acted upon within 7 days of the request.
Closure Date:
7 We recommended that processes be strengthened to ensure that HPC inpatients' pain is consistently assessed within 4 hours following an intervention and results documented in the EHR and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that pain interventions identified on HPC inpatients' IPCs are consistently implemented.
Closure Date:
9 We recommended that processes be strengthened to ensure that IPCs specify responsible team members.
Closure Date:
10 We recommended that processes be strengthened to ensure that the CLC social worker documents in the EHR that the CLC condolence letter was sent.
Closure Date:
11 We recommended that processes be strengthened to ensure that the COS reviews HRCP activities at least quarterly.
Closure Date:
12 We recommended that the facility establish an HRCT.
Closure Date:
13 We recommended that the facility conduct periodic, unscheduled onsite visits to the oxygen delivery contractor.
Closure Date:
14 We recommended that processes be strengthened to ensure that home oxygen program patients have active prescriptions and that patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
15 We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
Closure Date:
16 We recommended that processes be strengthened to ensure that prescribing clinicians conduct initial and follow-up evaluations of home oxygen program patients.
Closure Date:
17 We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
Closure Date:
18 We recommended that all members of the facility and unit-based expert panels receive the required training prior to the next annual staffing plan reassessment.
Closure Date:
19 We recommended that nursing managers monitor the staffing methodology that was implemented in August 2011.
Closure Date:
20 We recommended that the facility establish a policy outlining responsibilities of the multidisciplinary committee that oversees construction and renovation activities.
Closure Date:
21 We recommended that processes be strengthened to ensure that documentation of construction site inspections includes all required elements.
Closure Date:
22 We recommended that processes be strengthened to ensure that infection surveillance activities related to construction projects are conducted and documented in ICC minutes.
Closure Date:
23 We recommended that processes be strengthened to ensure that CSC minutes contain documentation of follow-up actions in response to unsafe conditions identified during inspections and that minutes track actions to completion.
Closure Date:
24 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
25 We recommended that processes be strengthened to ensure that when required, continuous negative air pressure is achieved prior to initiating work at a construction site.
Closure Date:
26 We recommended that processes be strengthened to ensure that physician orders and discharge summaries are consistent.
Closure Date:
| ||||
| 13-01741-215 | Combined Assessment Program Summary Report - Evaluation of Colorectal Cancer Screening and Follow-Up in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.
Closure Date:
| ||||
15353