Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-02908-21 | Alleged Misconduct by Construction and Facilities Deputy Executive Director Not Substantiated | Administrative Investigation | ||
1 The Executive Director of the Office of Construction and Facilities Management determines whether conducting special reviews should be conducted by the Quality Assurance Service, and if so, establishes policy or procedures to govern this type of work, including standardized processes for communicating and tracking the implementation of recommendations.
Closure Date:
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| 21-01682-25 | Inadequate Care Coordination for a Mental Health Residential Rehabilitation Treatment Program Resident in VISN 20, Oregon | Hotline Healthcare Inspection | ||
1 The Southern Oregon Rehabilitation Center and Clinics Director conducts an assessment to ensure all applicable elements of the Southern Oregon Rehabilitation Center and Clinics continuing care plan template are addressed when discharging residents from the Mental Health Residential Rehabilitation Treatment Program and takes action as warranted.
Closure Date:
2 The Southern Oregon Rehabilitation Center and Clinics Director ensures discharges of residents from the Mental Health Residential Rehabilitation Treatment Program occur during regular business hours in accordance with Veterans Health Administration Directive 1162.02.
Closure Date:
3 The Southern Oregon Rehabilitation Center and Clinics Director reviews Southern Oregon Rehabilitation Center and Clinics transportation policies to ensure alignment with Veterans
Health Administration transportation directives, including management of the transport of residents with behavioral flags.
Closure Date:
4 The Southern Oregon Rehabilitation Center and Clinics Director develops a process to ensure an updated medical evaluation is conducted should the admission team be notified of a change in
medical status that occurs after a veteran’s initial admission screening medical evaluation but prior to admission to the Mental Health Residential Treatment Program.
Closure Date:
5 The Southern Oregon Rehabilitation Center and Clinics Director completes a systematic review of residents’ falls in the shower area on the Mental Health Rehabilitation Residential Program units and takes action as warranted.
Closure Date:
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| 20-04237-09 | Audit of VA’s Compliance under the DATA Act of 2014 | Audit | ||
1 Continue the system modernization efforts that provide VA with the capability to generate the required DATA Act reporting files containing the necessary elements to meet compliance with the DATA Act. Ensure the modernization will provide the following:
a. Accurate reporting of object class, program activity codes, program activity names, and all other elements required by the DATA Act.
b. Award identification to allow VA to be able to develop a File C and reconcile the File C to both summary level data (Files A and B) and award level data (File D).
c. Reconciliations with subsidiary systems.
d. A mechanism to ensure transactions are reported that currently may be excluded due to the use of 1358s.
e. Standardized data fields to allow management to record an award ID across financial and supporting systems.
f. Subsidiary systems that are consistent with USSGL or adequately mapped to USSGL to ensure transactions contain the necessary data elements/field required to meet DATA Act reporting.
g. Differentiation between direct and reimbursable amounts.
2 Implement a grants management solution across all of VA’s grant programs and develop processes to ensure integration with the new reporting system.
Closure Date:
3 Improve researching of all root causes of differences between the VBA source systems and the monthly GTAS balances as part of their File B reconciliations. Also, differences should be accumulated and assessed at an aggregate level. The total differences either allocated to programs, reclassified out of other programs, or attributed to MinX JVs should be researched and reported as part of the SAO sub-certification process.
4 Continue mapping efforts and ensure programs without entitlement codes are recorded with the correct program activity codes and names rather than defaulting to Compensation.
5 Work with component level SAO’s to ensure timely receipt of signed certifications.
Closure Date:
6 Include more information in the SAO certifications, the Data Quality Plan document and the data submission about the costing and aggregation methodologies VA uses to report VHA data to increase transparency.
Closure Date:
7 Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for DATA Act reporting. The internal controls should ensure the following:
a. Excluded payments not reported due to zip code issues are researched, cleared, and reported in VBA’s life insurance FABS submission.
b. The default code “90” for Congressional District is not used when the county or zip code are unknown; instead, perform research to obtain the required data.
c. Guidance from OMB and Treasury is requested on the proper reporting of the face amount of insurance policies in VBA’s FABS submissions.
d. Management’s policies and procedures (e.g., Standard Operating Procedures) and narratives are updated on a timely basis in coordination with the VA PMO for the most current DATA Act submission procedures and reporting requirements.
Closure Date:
8 Ensure that reconciliations are complete, reconciling items are identified and researched, and any resolutions are clearly documented.
Closure Date:
9 Investigate potential controls or processes that could identify 1358s that should be reported until the system modernization can implement a solution.
10 Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for FABS reporting. The update should include and adhere to all FABS and DAIMS reporting requirements.
Closure Date:
11 Improve reviewing and validating eCMS actions to underlying contract documentation to assess the completeness and accuracy of data stored in eCMS. Identified exceptions should continue to be documented, and appropriate corrective actions (e.g., adequate training and guidance) should be completed to ensure and improve completeness and accuracy of data stored in eCMS.
Closure Date:
12 Coordinate and report system errors to Treasury on an as needed basis to ensure all required or derivable data elements are reported for FABS submission.
Closure Date:
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| 21-00275-11 | Comprehensive Healthcare Inspection of the Orlando VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Staff regularly attends Facility Surgical Workgroup meetings.
Closure Date:
2 The System 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 and Associate Director for Patient Care Services evaluate and
determine any additional reasons for noncompliance and ensure all required
representatives attend Disruptive Behavior Committee meetings.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their
work areas.
Closure Date:
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| 20-03898-236 | Improper Processing of Automated Pension Reductions Based on Social Security Cost of Living Adjustments | Review | ||
1 The OIG recommended the under secretary for benefits update the Veterans Benefits Administration’s adjudication procedures manual section related to notices of proposed adverse action to ensure automated notices align with the Veterans Affairs regulation, which requires material facts and detailed reasons for the proposed decision.
Closure Date:
2 The OIG recommended the under secretary for benefits amend the language of the automated notices of proposed adverse action to include all material facts and detailed reasons for the proposed decision.
Closure Date:
3 The OIG recommended the under secretary for benefits review all automatically completed fiscal year 2020 pension reductions based on Social Security cost of living adjustments to ensure regulations and procedures were followed, including consideration of supplementary medical insurance premiums and all evidence submitted by the beneficiary.
Closure Date:
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| 21-00270-04 | Comprehensive Healthcare Inspection of the VA Caribbean Healthcare System in San Juan, Puerto Rico | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses have actions and associated outcome measures.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and makes certain that core members regularly attend the Surgical Workgroup meetings.
Closure Date:
4 The 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:
5 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring physicians or the assigned designees send active medication lists to the receiving facilities during inter-facility transfers.
Closure Date:
6 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
7 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:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System.
Closure Date:
9 The Director evaluates and determines any additional reasons for noncompliance and ensures the required interdisciplinary team conducts a Workplace Behavioral Risk Assessment each fiscal year.
Closure Date:
10 The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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| 19-06004-225 | Veterans Integrated Service Network 21’s Management of Medical Facilities’ Nonrecurring Maintenance | Audit | ||
1 The director of the VA Sierra Pacific Network (VISN 21) should ensure out-of-cycle projects conform to NRM policy urgent-need criteria before approving projects.
Closure Date:
2 The director of VISN 21 should study the feasibility of using non-engineering staff to oversee NRM contracts, contracting out for project requirements to free up VISN engineering resources, and sharing engineering resources between VISN 21 facilities.
Closure Date:
3 The under secretary for health should implement an engineering staffing model for medical facilities that supports the achievement of VA strategic goals.
Closure Date:
4 The under secretary for health should perform annual reviews of the engineering staffing model to determine if adjustments are needed to achieve VA strategic goals.
Closure Date:
5 The under secretary for health should ensure medical facilities design long-range action plans that are feasible based on expected NRM budget levels.
Closure Date:
6 The executive director of the Office of Asset Enterprise Management, in coordination with the under secretary for health, should enforce NRM policy’s urgent-need criteria on out-of-cycle NRM project approvals.
Closure Date:
7 The under secretary for health in coordination with the executive director of the Office of Asset Enterprise Management should create a standardized set of performance measures and reporting standards for offices involved in developing, approving, and executing long-range action plans to ensure NRM projects that align with strategic goals are executed.
Closure Date:
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| 21-00274-289 | Comprehensive Healthcare Inspection of the James A. Haley Veterans' Hospital in Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines additional reasons for noncompliance and ensures the Surgical Workgroup conducts a monthly review of surgical deaths.
Closure Date:
2 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members participate in disruptive behavior event reviews.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training.
Closure Date:
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| 21-00267-290 | Comprehensive Healthcare Inspection of the Bay Pines VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures disclosure of adverse events that require an institutional disclosure.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Surgical Work Group reviews surgical deaths monthly.
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 prevention safety plans.
Closure Date:
4 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:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System include information regarding patients’ right to appeal the orders and the appeals process.
Closure Date:
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| 20-02014-270 | Vet Center Inspection of Southeast District 2 Zone 2 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons clinical and administrative quality reviews were not completed and monitors compliance.
Closure Date:
2 The District Director evaluates the clinical and administrative quality review report approval process to determine if a timeliness measure is needed and takes action as indicated.
Closure Date:
3 The District Director determines reasons clinical and administrative quality review remediation plans were not completed, ensures completion, and monitors compliance.
Closure Date:
4 The District Director evaluates the process for resolution of clinical and administrative quality review deficiencies and takes action as necessary.
Closure Date:
5 The District Director determines reasons for noncompliance with critical incident quality review (currently known as morbidity and mortality review) of a death by suicide, ensures completion includes an evaluation of vet center services to determine if actions are needed to improve the effectiveness of vet center suicide prevention activities, and monitors compliance.
Closure Date:
6 The District Director determines reasons for noncompliance with critical incident quality reviews (currently known as morbidity and mortality reviews) for serious suicide attempts, ensures completion, and monitors compliance.
Closure Date:
7 The District Director ensures intake assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
8 The District Director ensures military histories are completed and monitors compliance across all zone vet centers.
Closure Date:
9 The District Director ensures lethality risk assessments are completed and monitors compliance across all zone vet centers.
Closure Date:
10 The District Director, in collaboration with Readjustment Counseling Service Central Office, evaluates the limitations of current tools and tracking methods including reasons completion dates are unavailable in RCSnet and ensures compliance with standards for timely completion of intake assessments and military histories.
Closure Date:
11 The District Director determines reasons the Clearwater Vet Center did not have nontraditional hours as required and ensures compliance.
Closure Date:
12 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with the Clearwater, Ocala, Ponce, and Sarasota Vet Centers staff participation on mental health councils, and takes action as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
13 The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with vet centers’ receipt of the monthly Office of Mental Health and Suicide Prevention list of clients with an increased predictive risk for suicide, ensures coordination of care with VA medical facilities for vet center clients on the list, and monitors compliance.
Closure Date:
14 The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine the reasons updated lists of clients designated as high risk for suicide were not consistently received by vet centers, and ensures a process for vet centers’ receipt of the list in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding.
Closure Date:
15 The Under Secretary for Health ensures that the Chief Officer collaborates with the Office of Mental Health and Suicide Prevention to determine reasons for noncompliance with a standardized communication and collaboration process between suicide prevention coordinators and vet centers in accordance with the Office of Mental Health and Suicide Prevention and Readjustment Counseling Service Memorandum of Understanding, and initiates action as necessary.
Closure Date:
16 The District Director determines reasons for noncompliance with high risk for suicide flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk suicide flag at the Sarasota Vet Center, takes action to ensure requirement is met, and monitors compliance.
Closure Date:
17 The District Director determines reasons for noncompliance with processes for completing and tracking four hours of external clinical consultation per month at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures that vet center directors implement processes, and monitors compliance.
Closure Date:
18 The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
19 The District Director verifies and determines reasons for noncompliance with monthly RCSnet chart audits at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures chart audits are completed as required, and monitors compliance.
Closure Date:
20 The District Director determines reasons for errors in training assignments and why completed trainings are not being recorded for employees at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers, ensures all staff complete mandatory trainings as required, and monitors compliance.
Closure Date:
21 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Clearwater, Ocala, Ponce, and Sarasota Vet Centers and ensures all exit doors are compliant with the Architectural Barriers Act.
Closure Date:
22 The District Director reviews reasons for noncompliance with securing confidential and sensitive information at the Clearwater and Sarasota Vet Centers and ensures all vet center employees safely and securely store protected health information.
Closure Date:
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15039