Recommendations
2083
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-00295-61 | VA Needs Better Internal Communication and Data Sharing to Strengthen the Administration of Spina Bifida Benefits | Review | ||
1 The OIG recommended that the under secretary for benefits and the under secretary for health formalize interagency sharing processes between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care on how data and information will be shared between both offices to prevent payments from continuing to deceased spina bifida beneficiaries.
Closure Date:
2 The OIG recommended that the under secretary for benefits and the under secretary for health take the following actions establish clear written guidance on sharing beneficiary data between the Veterans Benefits Administration’s Denver regional office and the Veterans Health Administration’s Office of Community Care to ensure all entitled beneficiaries are enrolled in health care.
Closure Date:
3 The OIG recommended that the under secretary for benefits institute standardized procedures to help the Veterans Benefits Administration’s national call center agents provide accurate and comprehensive information about spina bifida benefits.
Closure Date:
4 The OIG recommended that the under secretary for health direct the Veterans Health Administration’s Office of Community Care to develop a process to ensure those beneficiaries who are not using the services for which they are eligible, or need assistance with locating those services, receive them.
Closure Date:
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| 19-09129-76 | VHA’s Response following Cardiac Catheterization Lab Closure at the Samuel S. Stratton VA Medical Center in Albany, New York | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health should publish written guidance that clarifies roles and responsibilities of the national Cardiology program office, Veterans Integrated Service Networks, and Chief Medical Officers to review and opine on interventional cardiologist applicant’s qualifications for employment in those cases when facilities lack local interventional cardiology expertise and the facility’s Chief of Staff seeks subject matter expert opinion.
Closure Date:
2 The Veterans Integrated Service Network Director reviews circumstances that led to the failure
to respond to an OIG request for additional information and alters the person-dependent process
accordingly to ensure future OIG referrals are responded to timely and completely.
Closure Date:
3 The Veterans Integrated Service Network Director reviews circumstances that led to the failure to respond to an OIG request for additional information and alters the person-dependent process accordingly to ensure future OIG referrals are responded to timely and completely.
Closure Date:
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| 18-00972-38 | Insufficient Oversight for Issuing Prosthetic Supplies and Devices | Audit | ||
1 Ensure Prosthetic and Sensory Aids Service business practice guidelines include specific requirements for conducting and properly documenting reviews of cloned and pending consults.
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2 Ensure Prosthetic and Sensory Aids Service staff develop a process to verify that consults include accessory and consumable supplies for prosthetic items prior to issuance.
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3 Ensure Prosthetic and Sensory Aids Service establishes field consistency requirements for conducting program reviews and evaluations.
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4 Ensure the executive director of the Prosthetic and Sensory Aids Service complies with existing policy for reviewing program assessments and evaluations and communicates review and evaluation results to the regional prosthetic representatives.
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| 20-00339-69 | Communication of Test Results and Oncology Scheduling Concerns at the Beckley VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Beckley VA Medical Center Director ensures that primary care providers comply with communicating laboratory test results to patients and documenting the discussion in accordance with Veterans Health Administration policy.
Closure Date:
2 The Beckley VA Medical Center Director ensures that the oncologist complies with facility scheduling and ordering policies including the Primary Care and Oncology Service Agreement.
Closure Date:
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| 20-01036-70 | Misconduct by a Gynecological Provider at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates review of policies related to the role and training requirements of providers, including gynecologists, who conduct sensitive exams, to determine the need for the inclusion of trauma-informed care principles into training, policy, and practice.
Closure Date:
2 The Under Secretary for Health ensures a review of policies related to the role and training requirements of chaperones for sensitive examinations and takes action as appropriate.
3 The South Central VA Health Care Network Director evaluates processes for tracking patient complaints, takes appropriate action to ensure that facility staff enter all complaints into the Patient Advocate Tracking System, and ensures that the data are tracked, trended, and analyzed to identify significant issues and trends.
Closure Date:
4 The Gulf Coast Veterans Health Care System Director ensures staff education of the Veterans Health Administration and Gulf Coast Veterans Health Care System policies related to employee misconduct and monitors compliance.
Closure Date:
5 The Gulf Coast Veterans Health Care System Director reviews and evaluates policies related to administrative investigations, including fact-finding reviews and administrative investigation boards, to ensure such investigations are timely, objective, and documentation is sufficient to address the event under review.
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6 The Gulf Coast Veterans Health Care System Director and facility leaders review the subject gynecologist’s conduct and quality of care provided and meet all Veterans Health Administration requirements for state licensing board and National Practitioner Data Bank reporting.
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| 20-01271-64 | Comprehensive Healthcare Inspection of the Dayton VA Medical Center in Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs include the minimum specialty-specific criteria for professional practice evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs complete and document focused professional practice evaluations on all newly hired licensed independent practitioners and evaluation results are reviewed and documented by the Clinical Executive Board.
Closure Date:
4 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
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5 The Medical Center Director determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
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6 The Medical Center Director determines the reasons for noncompliance and makes certain that the Multidisciplinary Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that qualified providers conduct four follow-up visits within 30 days of a High Risk for Suicide Patient Record Flag placement.
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8 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that clinicians complete patient safety plans within seven days before or after the current High Risk for Suicide Patient Record Flag date.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that life-sustaining treatment plans for patients who lack both decision-making capacity and a surrogate are referred to and reviewed by the assigned multidisciplinary committee.
Closure Date:
10 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
Closure Date:
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| 20-02779-59 | Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines | Hotline Healthcare Inspection | ||
1 The VA Manila Outpatient Clinic Manager evaluates the current pharmacy ordering processes and takes action to reduce the frequency of pharmacy stock shortages.
Closure Date:
2 The VA Manila Outpatient Clinic Manager reviews the impact of nonworking hours, including holidays, on pharmacy processing delays and takes action as necessary.
Closure Date:
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| 17-01980-201 | False Statements and Concealment of Material Information by VA Information Technology Staff | Administrative Investigation | ||
1 The Assistant Secretary for Information and Technology and Chief Information Officer confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the OIT program manager’s conduct.
Closure Date:
2 The Executive in Charge, Veterans Health Administration, confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the VHA employee’s conduct.
Closure Date:
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| 20-02339-35 | VA Needs to Comply Fully with the Geospatial Data Act of 2018 | Audit | ||
1 The acting assistant secretary for Enterprise Integration, in conjunction with the assistant secretary for Information and Technology, complies with requirement 3 in section 759(a) of the Geospatial Data Act to establish mandatory VA wide policies and responsibilities to promote the integration of geospatial data.
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2 The assistant secretary for Information and Technology, in conjunction with the director of Enterprise Records Service, establishes a process to ensure geospatial data and activities are included on VA record schedules that have been approved by the National Archives and Records Administration in accordance with requirement 4 of the law.
Closure Date:
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| 18-01321-56 | Thoracic Surgery Quality of Care Issues and Facility Leaders’ Response at the C.W. Bill Young VA Medical Center in Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health designates a thoracic specialty leader who has the authority to review all aspects of the personnel and management actions and can provide unbiased, authoritative, and timely guidance to facilities on the most clinically sound course of action when a thoracic surgeon’s practice or outcomes are under review, in order to ensure that VA provides high quality care.
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2 The Under Secretary for Health outlines general parameters and triggers for when facilities without local thoracic surgery expertise engage the thoracic specialty leader and how the thoracic specialty leader’s decisions and guidance will be documented.
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3 The Under Secretary for Health clarifies Veterans Health Administration policy regarding providers’ responsibilities to document complications in operative reports.
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4 The Under Secretary for Health reevaluates the eligible and mandatory assessment surgery cases reported to the National Surgery Office to determine if thoracic cases should be included in the list of mandatory assessment cases, and modifies the list as appropriate.
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5 The Under Secretary for Health defines expectations for peer review committee members whose cases are being reviewed to leave the room during those deliberations, provides guidance on how that recusal is to be annotated in the Peer Review Committee minutes, and updates Veterans Health Administration policy, as needed.
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6 The C.W. Bill Young VA Medical Center Director enhances processes to identify the existence of omissions or misrepresentations in operative note documentation and takes action based on identified deficiencies, if any.
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7 The C.W. Bill Young VA Medical Center Director takes action to ensure that the surgeon is aware of, and complies with, expectations for professional communications and supporting staff to report adverse events and close calls.
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8 The C.W. Bill Young VA Medical Center Director ensures the C.W. Bill Young VA Medical Center Surgical Work Group provides oversight as required by Veterans Health Administration policy and monitors for compliance.
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9 The C.W. Bill Young VA Medical Center Director confirms processes are in place to ensure providers’ clinical privileges are specific to the facility and service, and are based on each provider’s clinical competence, and monitors for compliance.
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10 The C.W. Bill Young VA Medical Center Director reviews whether the cases reflected in tables 1 and 2 in this report meet criteria for institutional disclosure and takes action as appropriate.
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15052