Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-07812-29 | Inadequate Oversight of VHA’s Home Oxygen Program | Audit | ||
1 The OIG recommended that the under secretary for health implement comprehensive guidance for staff who schedule home oxygen consults that includes processes for working with patients who do not or are unable to attend scheduled reevaluations, and for determining how and when to discontinue home oxygen services when appropriate.
Closure Date:
2 The OIG recommended that the under secretary for health update guidance to include any exceptions to the scheduling time frame based on the type of home oxygen services patients are prescribed.
Closure Date:
3 The OIG recommended that the under secretary for health update policy to assign oversight responsibility for ensuring the number of home or telehealth visits outlined in guidance is conducted.
Closure Date:
4 The OIG recommended that the under secretary for health require the network contracting offices to provide oversight so that (1) contracting officers ensure vendor performance evaluations and quality assurance reports are completed and documented in the electronic contract management system, and (2) contracting officers comply with requirements when designating contracting officer’s
representatives.
Closure Date:
5 The OIG recommended that the under secretary for health clearly communicate processes or tools that staff should use to achieve the contract monitoring requirements outlined in the Federal Acquisition Regulation.
Closure Date:
6 The OIG recommended that the under secretary for health ensure facilities in Veterans Integrated Service Network 7 review orders that were paid for home oxygen services without an awarded contract and submit a request for ratification to the head of the contracting activity for any unauthorized commitments.
Closure Date:
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| 21-01801-45 | Deficiencies in the Care of a Patient with Gastrointestinal Symptoms at the Eastern Oklahoma Health Care System in Muskogee | Hotline Healthcare Inspection | ||
1 The Eastern Oklahoma VA Health Care System Facility Director reviews processes to ensure patients with ordered Fecal Immunochemical Test (FIT) are tracked according to Veterans Health Administration policy, documentation is complete, and takes action if necessary.
Closure Date:
2 The Eastern Oklahoma VA Health Care System Facility Director evaluates processes for Emergency Department providers’ physical examinations when a patient presents with gastrointestinal symptoms that include associated bleeding and determines if modifications, including provider education, are needed.
Closure Date:
3 The Eastern Oklahoma VA Health Care System Facility Director ensures that patient advocates and Primary Care leaders perform thorough reviews of all components of complaints for resolution and patient advocates document according to policy.
Closure Date:
4 The Eastern Oklahoma VA Health Care System Facility Director ensures facility leaders monitor complaints and take action on issues that are identified related to the Emergency Department physician’s performance.
Closure Date:
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| 21-00942-16 | Financial Efficiency Review of the Eastern Oklahoma VA Health Care System | Financial Inspection | ||
1 The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure finance office staff are made aware of policy requirements and reviews are conducted on all open obligations as required by VA Financial Policies and Procedures, vol. 2, chap. 5, “Obligations Policy,” January 2018.
Closure Date:
2 The OIG recommended the director of contracting for Network Contracting Office 19, VA Rocky Mountain Network, develop checks on the successful completion of quarterly audits of the purchase card program as required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
Closure Date:
3 The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interests of the government.
Closure Date:
4 The OIG recommended the director of the Eastern Oklahoma VA Health Care System ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
Closure Date:
5 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop measures to confirm completed VA Form 0242 submissions are accurate and updated for all cardholders.
Closure Date:
6 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop formalized processes for achieving identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
7 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to increase inventory turnover closer to the VHA recommended level.
Closure Date:
8 The OIG recommended the director of the Eastern Oklahoma VA Health Care System develop and implement a plan to complete facility based inventory audits of noncontrolled drug line items in compliance with VHA policy.
Closure Date:
9 The OIG recommended the director of the Eastern Oklahoma VA Health Care System establish measures to improve compliance with the nonformulary request process.
Closure Date:
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| 19-09592-262 | Improvements Needed to Ensure Final Disposition of Unclaimed Veterans’ Remains | Review | ||
1 The OIG recommended the assistant secretary for the Office of Enterprise Integration designate a senior accountable official or program office for the full scope of benefits and services provided on behalf of deceased veterans whose remains are unclaimed. This official or office should be charged with ensuring that VA’s benefits and services for unclaimed veterans comply with applicable federal enterprise risk management and internal control standards.
Closure Date:
2 The OIG recommended the assistant secretary for the Office of Enterprise Integration conduct a program evaluation of all VA benefits and services for deceased veterans whose remains are unclaimed in compliance with applicable laws and VA regulations. This evaluation should consider the extent to which existing law requires VA to conduct outreach on behalf of deceased veterans whose remains are unclaimed. This evaluation should also ensure the benefits and services are assigned to the appropriate VA program offices and the offices are given authority to administer these programs.
Closure Date:
3 The OIG recommended the assistant secretary for the Office of Enterprise Integration coordinate and implement data sharing agreements with other agencies or organizations with records of deceased veterans whose remains are unclaimed or veterans not included in VA databases.
Closure Date:
4 The OIG recommended the assistant secretary for the Office of Enterprise Integration determine eligibility and take action to facilitate dignified burials for these persons with unclaimed remains whose records the OIG referred to VA.
Closure Date:
5 The OIG recommended the assistant secretary for the Office of Enterprise Integration develop a comprehensive estimate of the number of deceased veterans whose remains are unclaimed awaiting burial, including those held at locations other than funeral homes.
Closure Date:
6 The OIG recommended the assistant secretary for management and chief financial officer implement controls for payments made to individual payees or other entities on behalf of deceased veterans whose remains are unclaimed that can be cross referenced across current VA payment systems and ensure that staff involved with issuing payments are trained in the correct use of these controls.
Closure Date:
7 The OIG recommended the under secretary for benefits implement monitoring mechanisms, procedures, and recurring training for VA regional office directors on their responsibilities for facilitating burials for deceased veterans whose remains are unclaimed.
Closure Date:
8 The OIG recommended the under secretary for benefits require points of contact for indigent and unclaimed veterans outreach to regularly complete the outreach functions listed in VA Manual 27 1, chapter 11. VBA should ensure points of contact receive recurring training in these tasks and implement ongoing compliance activities.
Closure Date:
9 The OIG recommended the under secretary for health direct VHA leadership to assess the extent to which personnel in the former VHA Office of Operations and Management and the VHA Office of Member Services were not performing required oversight activities and take appropriate action.
Closure Date:
10 The OIG recommended the under secretary for memorial affairs
implement system indicators in NCA systems to show when veterans’ remains are unclaimed without relying on a manually updated spreadsheet. These system indicators should enable tracking mechanisms to ensure required follow ups are performed on completed burial eligibility determinations without a scheduled interment and identify repeat burial eligibility requests.
Closure Date:
11 The OIG recommended the under secretary for memorial affairs
in coordination with the Secretary’s Center for Strategic Partnerships, assess options for providing a suitable casket or urn to a deceased veteran whose remains are unclaimed rather than a monetary reimbursement.
Closure Date:
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| 20-04219-07 | Follow-Up Review of the Accuracy of Special Monthly Compensation Housebound Benefits | Review | ||
1 Review all active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
Closure Date:
2 Implement a plan to conduct ongoing periodic reviews of completed active high-risk special monthly compensation housebound cases, render new decisions as appropriate, ensure the corrective actions were taken, and conduct a documented quality review of corrective actions.
Closure Date:
3 Update the special monthly compensation housebound training to include guidance on and examples of statutory, housebound in fact, individual unemployability, and extraschedular criteria, and monitor the effectiveness of the training.
Closure Date:
4 Create a system enhancement to limit the statutory special monthly compensation housebound validation warning to trigger only when statutory housebound criteria are met but not addressed.
Closure Date:
5 Create a system enhancement to prohibit rating veterans service representatives from bypassing statutory housebound validation warnings without taking action or providing justification.
Closure Date:
6 Correct all processing errors on cases identified by the review team and report the results to the OIG.
Closure Date:
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| 21-00278-23 | Comprehensive Healthcare Inspection of the Hampton VA Medical Center in Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that required members regularly attend Surgical Workgroup meetings.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
4 The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that appropriately privileged transferring providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to inter-facility patient transfers.
Closure Date:
5 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
6 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 area.
Closure Date:
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| 21-00277-41 | Comprehensive Healthcare Inspection of the Fayetteville VA Coastal Health Care System in North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Workgroup meets monthly and core members consistently attend meetings.
Closure Date:
2 The OIG recommends that the principal executive director, Office of Acquisition, Logistics, and Construction direct the Strategic Acquisition Center’s Medical/Surgical Prime Vendor Program contracting officer to provide guidance to Veterans Integrated Service Network and VA medical facilities’ program contracting officer’s representatives on the emergency and
continuous supply provisions in the contracts, and ensure contracting officers’ representatives inform network and facility managers of the strategies offered by the prime vendors.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to the receiving facilities during inter-facility transfers.
Closure Date:
4 The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
5 The Chief of Staff and Associate Director of Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that all required members attend Disruptive Behavior Committee meetings.
Closure Date:
6 The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.1
Closure Date:
7 The Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete required training.
Closure Date:
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| 21-01049-39 | Deficiencies in Disclosures and Quality Processes for Perforations Resulting from Urological Surgeries at West Palm Beach VA Medical Center in Florida | Hotline Healthcare Inspection | ||
1 The West Palm Beach VA Medical Center Director evaluates clinical disclosure practices and takes action as warranted to ensure compliance with Veterans Health Administration Directive 1004.08.
Closure Date:
2 The West Palm Beach VA Medical Center Director ensures that Patient A’s and Patient B’s episodes of care are reviewed to determine if an institutional disclosure is needed per Veterans Health Administration Directive 1004.08 and takes action accordingly.
Closure Date:
3 The West Palm Beach VA Medical Center Director evaluates facility compliance with Veterans Health Administration Directive 1004.08 regarding institutional disclosure processes and takes corrective actions as needed.
Closure Date:
4 The West Palm Beach VA Medical Center Director explores reasons Joint Patient Safety Reports were not entered for some adverse events experienced by Patient A and Patient B and takes action accordingly to ensure compliance with Veterans Health Administration Handbook 1050.01.
Closure Date:
5 The West Palm Beach VA Medical Center Director confirms that the Surgical Workgroup’s meeting minutes document oversight of the Surgical Service Morbidity and Mortality Conference by including issues discussed, conclusions, actions, recommendations, evaluations, and follow up in accordance with Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
Closure Date:
6 The West Palm Beach VA Medical Center Director identifies reasons a planned peer review was not completed in accordance with Veterans Health Administration Directive 1190 and takes corrective action as indicated.
Closure Date:
7 The West Palm Beach VA Medical Center Director reviews processes for evaluation of urologists’ privileging forms and takes action as necessary to ensure compliance with Veterans Health Administration Handbook 1100.19 and Bylaws and Rules of the Medical Staff Department of Veterans Affairs Medical Center West Palm Beach, Florida.
Closure Date:
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| 20-01099-249 | VHA Improperly Paid and Reauthorized Non-VA Acupuncture and Chiropractic Services | Audit | ||
1 Ensure the Office of Community Care implements automated payment system controls to reject non VA claims that exceed the number of authorized visits or cutoff dates or includes treatment codes that deviate from established standards for care.
Closure Date:
2 Ensure the Office of Community Care conducts ongoing payment system audits to identify and minimize improper payments of unauthorized claims.
Closure Date:
3 Direct the Health Information Management program office in coordination with the Office of Community Care and facility chiefs of staff to ensure facilities are conducting post payment audits of billed acupuncture and chiropractic services to verify non VA providers are properly supporting their claims and to develop processes for corrective actions based on audit results.
4 Ensure the Office of Community Care and the Health Information Management program office, in coordination with the offices of Acupuncture and Chiropractic services, make any current and future continuing education material related to documenting acupuncture and chiropractic services available to non VA providers.
Closure Date:
5 Direct facility chiefs of staff to require those authorized to approve non VA care to document review of prior care before approving additional services.
Closure Date:
6 Instruct facility chiefs of staff to require VA providers to document their clinical justification for additional care requested by a veteran.
Closure Date:
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| 21-01807-251 | VHA Risks Overpaying Community Care Providers for Evaluation and Management Services | Review | ||
1 Direct the Health Information Management program office, in coordination with the Office of Community Care and facility chiefs of staff, to ensure facilities are conducting post payment audits of billed evaluation and management services to verify non VA providers are properly supporting their claims, including a focus on providers who frequently bill high level evaluation and management services and/or submit charges during periods when global surgery packages are in effect, and develop processes for corrective actions based on audit results.
2 Ensure the Office of Community Care and the Health Information Management program office make any current and future continuing education material related to documenting evaluation and management services available to non VA providers.
Closure Date:
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15039