Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-02201-200 | Senior Staff Gave Inaccurate Information to OIG Reviewers of Electronic Health Record Training | Administrative Investigation | ||
1 Issue a clarifying communication to the office’s personnel that all staff have a right to speak directly and openly with Office of Inspector General staff without fear of retaliation, and that, irrespective of any processes established to facilitate the flow of information, Electronic Health Record Modernization Integration Office personnel are encouraged to communicate directly with OIG staff when needed to proactively clarify requests and avoid confusion.
Closure Date:
2 Provide clear guidance that the office’s personnel must provide timely, complete, and accurate responses to requests for all data or information without alteration, unless other formats are requested, with full disclosure of the methodology, any data limitations, or other relevant context. This includes prompt OIG access to entire datasets consistent with the Inspector General Act of 1978, as amended.
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3 Determine whether any administrative action should be taken with respect to the conduct or performance of the executive director of Change Management.
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4 Determine whether any administrative action should be taken with respect to the conduct or performance of Change Management’s director for training strategy.
Closure Date:
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| 21-00239-180 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 5: VA Capitol Health Care Network in Linthicum, Maryland | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines the reason for noncompliance, reviews the credentials file, and approves the VA appointment for physicians who had a potentially disqualifying licensure action.
Closure Date:
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| 21-00287-194 | Comprehensive Healthcare Inspection of the Martinsburg VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures leaders properly identify adverse events as sentinel events when criteria are met and conduct institutional disclosures, as required.
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2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Health Systems Specialist participates on the VISN Systems Redesign Review Advisory Group.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend Facility Surgical Workgroup meetings.
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4 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate all patient transfers.
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5 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
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6 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to receiving facilities during inter-facility transfers.
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7 The Chief of Staff and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members consistently attend Disruptive Behavior Committee meetings.
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8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all Employee Threat Assessment Team members complete the required training.
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9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
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| 21-02599-156 | Contract Closeout Compliance Needs Improvement at Regional Procurement Offices Central and West | Review | ||
1 Establish procedures for consistent quality assurance reviews to ensure all contract closeout requirements, such as identifying and deobligating excess funds, closing out contracts timely, and properly completing and uploading closeout documentation, are performed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, update Veterans Health Administration policies and procedures to provide guidance on conducting and documenting the reviews.
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2 Assess and determine how to effectively distribute contracting officer workload and address imbalances among staff to help ensure contract closeouts are completed in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
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3 Clarify the Veterans Health Administration procurement manual to indicate when simplified acquisition procedures closeout processes are to be used and the documentation requirements for each contract closeout step.
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4 Determine whether setting aside specific time weekly to focus on contract administration tasks, such as contract closeout, and using contractors to perform closeout procedures could improve contract closeout compliance.
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5 Ensure the contract files for the 81 sampled contracts have complete closeout documentation in accordance with the Federal Acquisition Regulation and the Veterans Health Administration procurement manual.
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| 21-03853-174 | Financial Efficiency Review of the VA Boston Healthcare System in Massachusetts | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations, and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
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2 Ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Programs.”
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3 Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
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4 Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
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5 Ensure quarterly purchase card audits are performed as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
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6 Ensure supply chain management staff implement a plan to improve data reliability within the Generic Inventory Package system.
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7 Ensure the chief of supply chain management signs quarterly physical inventory memorandums of “A” classified items and makes them available to Veterans Integrated Service Network personnel as required in the VHA’s Directive 1761 Supply Chain Management Operations.
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8 Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.
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| 21-03195-189 | Pharmacists’ Practices Delayed Buprenorphine Refills for Patients with Opioid Use Disorder at the New Mexico VA Health Care System in Albuquerque | Hotline Healthcare Inspection | ||
1 The New Mexico VA Health Care System Director ensures that facility practice is consistent with Veterans Health Administration and facility policy applicable to early refills of buprenorphine for patients receiving opioid agonist therapy for opioid use disorder and is consistent with evidence-based treatment and prescribing providers’ clinical rationale, ensures all relevant staff are educated on the policy, and monitors for compliance with policy.
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2 The New Mexico VA Health Care System Director ensures communication between provider, pharmacist, and patient for early medication refills and monitors for compliance with Veterans Health Administration policy.
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3 The New Mexico VA Health Care System Director clarifies the roles and responsibilities of the Opioid Safety Committee as related to buprenorphine treatment for patients with opioid use disorder, and ensures relevant staff are educated regarding the Opioid Safety Committee’s role in buprenorphine treatment.
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4 The New Mexico VA Health Care System Director reviews buprenorphine prescribing provider concerns regarding the Opioid Agonist Therapy (Buprenorphine) for Opioid Use Disorder standard operating procedure and ensures the planned revision and implementation of the standard operating procedure is consistent with evidence-based treatment and includes language that specifies allowance for clinical judgment and a patient-centered care approach.
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5 The New Mexico VA Health Care System Director reviews prescribing provider staffing levels in accordance with the Substance Use Disorder program’s needs and facility’s plans for expanding buprenorphine treatment in other clinical areas, and develops an action plan to address recommendations, if any, from the staffing level review.
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| 21-01898-152 | VA Medical Facilities Took Steps to Safeguard Refrigerated Pharmaceuticals but Could Further Reduce the Risk of Loss | Audit | ||
1 Direct the assistant under secretary for health operations to reinforce to medical facility directors the importance of establishing a process to ensure facility managers include pharmaceutical refrigerators and freezers in the facility’s routine maintenance schedules and develop and implement a procedure to make sure medical facilities follow VHA Notice 2021-16.
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2 Require the assistant under secretary for patient care services to coordinate with the assistant under secretary for health operations to update the 10N Guide to VHA Issue Briefs and clarify that medical facilities must report all refrigerated pharmaceutical loss via the issue brief tracker.
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| 21-03201-185 | Failure of Leaders to Address Safety, Staffing, and Environment of Care Concerns at the Tuscaloosa VA Medical Center in Alabama | Hotline Healthcare Inspection | ||
1 The Tuscaloosa VA Medical Center Director provides oversight of the purchase and installation of an electronic alarm system for all Community Living Center neighborhoods and cottages and confirms ongoing monitoring of its use after installation.
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2 The Tuscaloosa VA Medical Center Director confirms completion of the risk analysis recommended in the facility-initiated risk assessment to determine if the Azalea House is suitable for the patient population residing there.
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3 The Tuscaloosa VA Medical Center Director ensures that all security cameras are operable and labeled appropriately and develops and monitors a plan for ongoing testing and maintenance.
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4 The Tuscaloosa VA Medical Center Director directs staff to assess the effectiveness of the outdoor fencing and gates surrounding Azalea House as a security measure to prevent Community Living Center residents at-risk for elopement from leaving the facility campus.
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5 The Tuscaloosa VA Medical Center Director establishes a review process to ensure that Community Living Center residents determined to be high risk for elopement have documentation consistent with Tuscaloosa VA Medical Center policy in their electronic health records identifying residents’ risk status.
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6 The Tuscaloosa VA Medical Center Director collaborates with the Veterans Integrated Service Network 7 Senior Strategic Business Partner to determine difficult to fill job series and develops a plan to maximize use of available tools for coverage, recruitment, and retention.
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7 The Tuscaloosa VA Medical Center Director ensures completion of a review of the facility’s Comprehensive Environment of Care program to confirm that patient care areas are properly classified, all areas are inspected at the required frequency, and compliance is monitored.
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8 The Tuscaloosa VA Medical Center Director coordinates with subject matter experts and develops a plan to ensure that the facility’s Comprehensive Environment of Care program effectively identifies areas in need of attention to provide a clean and safe environment for patients, visitors, and staff.
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9 The Tuscaloosa VA Medical Center Director confirms that Engineering Service staff conduct rounds of the grounds according to Tuscaloosa VA Medical Center policy.
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10 The VA Southeast Network 7 Director ensures completion of the Tuscaloosa VA Medical Center’s action plan to address recommendations made as a result of the October 2021 Veterans Integrated Service Network site visit.
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| 21-03349-186 | Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director ensures that providers communicate, act on, and document a review of test results consistent with Veterans Health Administration policy.
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2 The Hampton VA Medical Center Director determines why the abnormal prostate-specific-antigen test results were not alerted to an ordering or surrogate provider and if other patient test results during that time frame also warrant review.
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3 The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.
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4 The Hampton VA Medical Center Director reviews the urology consult template and, if appropriate, ensures the specific imaging required for consultation is specified in the template.
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5 The Hampton VA Medical Center Director ensures that procedures are in place to identify and reduce errors when staff place nuclear medicine orders.
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6 The Hampton VA Medical Center Director ensures that facility staff submit patient safety reports consistent with Veterans Health Administration and Hampton VA Medical Center policy.
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7 The Hampton VA Medical Center Director ensures that quality management staff initiate timely quality reviews when deficiencies in patient care are identified.
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| 22-00576-178 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2021 | Review | ||
1 The acting under secretary for health take necessary measures to reduce improper and unknown payments to below 10 percent for Beneficiary Travel, Medical Care Contracts and Agreements, Purchased Long-Term Services and Supports, and VA Community Care programs and activities.
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15039