Recommendations
2083
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-01265-172 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 10: VA Healthcare System Serving Ohio, Indiana and Michigan in Cincinnati | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the credentials files of physicians who had a potentially disqualifying licensure action are reviewed with Regional Counsel, or a designee, and submitted for approval of VA appointment.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and appoints a Veterans Integrated Service Network lead women veterans program manager.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead women veterans program manager provides quarterly program updates to executive leaders.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead women veterans program manager completes annual site visits at each facility within the Veterans Integrated Service Network.
Closure Date:
5 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
Closure Date:
6 The Network Director determines the reasons for noncompliance and makes certain that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
Closure Date:
7 The Network Director determines the reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead oversees facility development of corrective action plans within the required time frame and tracks action items until closure.
Closure Date:
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| 20-01646-139 | VHA Made Inaccurate Payments to Part-Time Physicians on Adjustable Work Schedules | Audit | ||
1 Ensure payroll personnel complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.
Closure Date:
2 Establish oversight procedures to make certain that part-time physicians submit and validate their subsidiary time sheets and that supervisors promptly certify the time sheets.
Closure Date:
3 Train newly assigned payroll personnel on agreement reconciliation procedures and develop follow-up procedures to prevent missed reconciliations because of staff turnover.
Closure Date:
4 Implement procedures to confirm service chiefs conduct quarterly reviews of all adjustable work hour agreements that include identifying physicians with significant variances from the agreements or indicators that the cap on part-time hours is likely to be exceeded and taking corrective actions.
Closure Date:
5 Document oversight procedures for monitoring and validating compliance with the requirements of the part-time physician on adjustable work schedules program.
Closure Date:
6 Direct the program office, in coordination with the VA Office of General Counsel, to determine whether medical centers committed Antideficiency Act violations by not correcting underpayments and preventing physicians from working above the annual limit of 1,820 hours.
Closure Date:
7 Establish oversight procedures for monitoring and validating their medical centers’ compliance with the requirements of the part-time physician on adjustable work schedules program.
Closure Date:
8 Complete overdue reconciliations of part-time physicians on adjustable work schedule agreements and take any necessary actions to address overpayments and underpayments.
Closure Date:
9 Document oversight procedures for monitoring and validating that all reconciliations and payment corrections are completed when agreements expire or are terminated.
Closure Date:
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| 20-00354-178 | Failure of a Primary Care Provider to Complete Electronic Health Record Documentation and Inadequate Oversight at the Charlie Norwood VA Medical Center in Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Charlie Norwood VA Medical Center Director confirms that the Chief of the Health Information Management program monitors documentation to include patient care episodes without an associated progress note as part of the ongoing electronic health record review process, and takes action as warranted.
Closure Date:
2 The Charlie Norwood VA Medical Center Director ensures a policy defines the required time frame for providers to respond to view alerts.
Closure Date:
3 The Charlie Norwood VA Medical Center Director continues to monitor providers’ compliance with responding to view alerts, evaluates the effectiveness of the implemented strategies to reduce unnecessary view alerts, and assesses the need for retrospective reviews of patient care related to accumulated view alerts.
Closure Date:
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| 20-00345-77 | Inadequate Oversight of Contractors’ Personal Identity Verification Cards Puts Veterans’ Sensitive Information and Facility Security at Risk | Review | ||
1 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers obtain and maintain evidence of contractor-provided lists of all personal identity verification cards issued to contractor employees.
2 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to ensure contracting officers maintain evidence documenting personal identity verification cards were returned to the issuing or designated office when the cards were no longer required and prior to closing the contract.
3 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to evaluate the role of contracting officer’s representatives in the personal identity verification card process for contractor employees and assess whether updates to their letter of delegation and standard operating procedures are necessary.
4 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish policies and procedures outlining specific supervisory responsibilities for contracting officer oversight in accordance with the Government Accountability Office Standards for Internal Controls in the Federal Government.
Closure Date:
5 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess the contract completion statement template to determine whether to include the contractor-related personal identity verification card requirements.
Closure Date:
6 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures within the Procurement Audit Office for periodic reviews of contract files to determine compliance with the personal identity verification card requirements established in the Federal Acquisition Regulation and the Veterans Health Administration procurement manual. Further, require the results of these reviews to be reported to senior management to help determine whether corrective actions are required.
7 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to determine whether existing or planned systems can have the functionality to allow management to effectively and routinely monitor contractor employee personal identity verification cards or whether a new system should be established.
Closure Date:
8 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to assess whether contracting officers should be required to include the contractor-provided list as an explicit requirement in all Veterans Health Administration contracts that require issuance of personal identity verification cards to contractor employees.
9 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to establish procedures to ensure contracting officers include Federal Acquisition Regulation clause 52.204-9, “Personal Identity Verification of Contractor Personnel,” in contracts when required.
Closure Date:
10 The OIG recommended the acting under secretary for health collaborate, as necessary, with other offices within VA that have responsibilities regarding personal identity verification cards to consider directing contracting officers to delay final payment to contractors on future contracts until all personal identity verification cards have been returned.
Closure Date:
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| 19-09808-171 | Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health ensures the Office of Connected Care Telehealth Services and the Office of Mental Health and Suicide Prevention collaborate to develop a consistent process for facility implementation of telehealth emergency plans tailored for telehealth care and the patient-clinic locations that are inclusive of procedures addressing mental health and medical emergencies and technological disruptions during telemental health care.
Closure Date:
2 The Under Secretary for Health verifies the Office of Connected Care Telehealth Services reviews and implements oversight of telehealth emergency plan processes to include expectations for updating and monitoring.
Closure Date:
3 The Under Secretary for Health confirms the Office of Connected Care Telehealth Services develops consistent processes for healthcare systems to define and communicate individual telehealth staff responsibilities during telehealth emergencies, specific to the patient-clinic locations.
Closure Date:
4 The Under Secretary for Health ensures the Office of Connected Care Telehealth Services has a consistent process for healthcare systems to develop, maintain and communicate accurate, patient-clinic location specific telehealth emergency contact information to all telehealth staff, to include remote providers.
Closure Date:
5 The Under Secretary for Health collaborates with the Office of Connected Care Telehealth Services to develop a streamlined process to report patient safety events specific to telehealth that clearly identifies the setting and specific service line to allow tracking, trending, and monitoring.
Closure Date:
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| 20-00176-125 | Veterans Cemetery Grants Program Did Not Always Award Grants to Cemeteries Correctly and Hold States to Standards | Audit | ||
1 The OIG recommended the under secretary for memorial affairs develop controls to ensure state grants are prioritized and awarded in accordance with the Code of Federal Regulations.
Closure Date:
2 The OIG recommended the under secretary for memorial affairs develop and implement written policies and procedures for grant prioritization.
Closure Date:
3 The OIG recommended the under secretary for memorial affairs evaluate all current national headstone and niche cover contracts for appropriate penalties and clauses for timeliness and quality issues and enforce and amend those contracts as necessary.
Closure Date:
4 The OIG recommended the under secretary for memorial affairs direct the Improvement and Compliance Service to assign levels of importance to standards and measures used for compliance reviews and test the inscription accuracy of all gravesites sampled.
Closure Date:
5 The OIG recommended the under secretary for memorial affairs require all state and tribal cemeteries to submit certified condition and operations performance assessments annually.
Closure Date:
6 The OIG recommended the under secretary for memorial affairs ensure representatives from all state and tribal cemeteries are provided opportunities to participate in National Cemetery Administration standards training via remote training options and monitor all training to ensure adequate participation.
Closure Date:
7 The OIG recommended the under secretary for memorial affairs continue to seek an increase in cemetery grant funding in excess of $45 million
Closure Date:
8 The OIG recommended the under secretary for memorial affairs ensure that the Improvement and Compliance Service follows up with Hawaiian cemeteries after action plans are submitted to ensure deficiencies are corrected.
Closure Date:
9 The OIG recommended the under secretary for memorial affairs implement controls to ensure cemeteries that receive provisionally compliant or noncompliant scores during reviews are followed up with on a fixed and regular basis until sufficient corrective action plans are submitted.
Closure Date:
10 The OIG recommended the under secretary for memorial affairs use accountability measures in the Code of Federal Regulations when appropriate if grantees do not take adequate steps to correct significant long standing deficiencies.
Closure Date:
11 The OIG recommended the under secretary for memorial affairs work with the State of Hawaii Office of Veterans’ Services to conduct an extensive assessment of all eight Hawaii state veterans cemeteries, including organizational oversight and operations, staffing needs (including training), gravesite marker accuracy, and grounds conditions.
Closure Date:
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| 20-01273-162 | Comprehensive Healthcare Inspection of the John D. Dingell VA Medical Center in Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a first- or second-line supervisor completes a provider exit review form within seven business days of a licensed independent practitioner’s departure from the medical center.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all employees complete suicide prevention refresher training.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned to the Women Veterans Health Committee.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
Closure Date:
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| 20-01141-145 | VHA Needs More Reliable Data to Better Monitor the Timeliness of Emergency Care | Audit | ||
1 The OIG recommended the under secretary for health
ensure Baltimore VA Medical Center leaders reevaluate their corrective action plan and adjust as needed.
Closure Date:
2 The OIG recommended the under secretary for health make certain relevant staff receive appropriate training on recording wait times in the software.
Closure Date:
3 The OIG recommended the under secretary for health strengthen reliability reviews of Emergency Department Integration Software data to mitigate the risk of inaccurate records.
Closure Date:
4 The OIG recommended the under secretary for health establish routine oversight responsibilities for Veterans Integrated Service Network and facility leaders of emergency departments’ efforts to improve the reliability of their emergency department data.
Closure Date:
5 The OIG recommended the under secretary for health improve the monitoring of data for patients with the highest Emergency Severity Index levels of one or two receiving emergency care services.
Closure Date:
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| 20-02968-170 | Improper Feeding of a Community Living Center Patient Who Died and Inadequate Review of the Patient’s Care, VA New York Harbor Healthcare System in Queens | Hotline Healthcare Inspection | ||
1 The VA New York Harbor Healthcare System Director reviews the process of evaluating the Community Living Center nursing staff’s competency for resident feeding and validates their ability to safely feed residents.
Closure Date:
2 The VA New York Harbor Healthcare System Director ensures that Community Living Center nursing staff are trained on documentation requirements related to feeding of residents and verifies compliance with requirements.
Closure Date:
3 The VA New York Harbor Healthcare System Director evaluates documentation of resident feeding, including identifying the staff member who feeds a resident, and takes action as indicated.
Closure Date:
4 The VA New York Harbor Healthcare System Director verifies that a comprehensive review of the patient’s care and death is completed, and evaluates the usefulness of including the pictures and video of the chicken in the review, and takes action as indicated.
Closure Date:
5 The VA New York Harbor Healthcare System Director ensures the Cardiopulmonary Resuscitative Committee evaluates identified issues and makes recommendations for improvement, confirms actions are implemented, and assesses the effectiveness of actions.
Closure Date:
6 The VA New York Harbor Healthcare System Director verifies staff are aware of what constitutes an adverse event and the requirements to submit incident reports when witnessing or becoming aware of an adverse event.
Closure Date:
7 The VA New York Harbor Healthcare System Director evaluates the circumstances surrounding the patient’s death to determine if an institutional disclosure is warranted
Closure Date:
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| 20-01485-114 | Inspection of Information Technology Security at the VA Outpatient Clinic in Austin, Texas | Information Security Inspection | ||
1 The OIG recommended the area manager for the Central Texas Veterans Health Care System implement more effective automated inventory management tools.
Closure Date:
2 The OIG recommended the area manager for the Central Texas Veterans Health Care System implement a more effective patch and vulnerability management program that can accurately identify vulnerabilities and enforce patch application.
Closure Date:
3 The OIG recommended the area manager for the Central Texas Veterans Health Care System ensure compliance with the media protection standard operating procedure for all employees who work with media storage and ensure compliance with marking and sanitization provisions.
Closure Date:
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15052