Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00230-190 | Waste and Abuse by the Former Assistant Secretary for Human Resources and Administration | Administrative Investigation | ||
1 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction requires in any award made on a noncompetitive basis that the contracting officer obtain a written disclosure and certification by the program sponsor, contracting officer’s representative, and other staff involved in the procurement as appropriate, disclosing any personal or professional relationship between such staff and vendor personnel.
Closure Date:
2 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the conduct and performance of the contracting officer, the Agency Competition Advocate, and the two higher-level supervisors involved in this procurement.
Closure Date:
3 The Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness determines what administrative action should be taken, if any, with respect to the conduct and performance of the HR&A Program Director and the Contracting Officer’s Representative.
Closure Date:
4 VA’s Senior Procurement Executive determines what action, if any, should be taken with respect to the contracting officer’s warrant consistent with the authority granted by VA Acquisition Regulation § 801.690-6.
Closure Date:
5 The Acting General Counsel reviews the circumstances of this procurement and uses that information to help determine whether it is appropriate for counsel to sign attestations on Justification and Approval forms, and issues policy guidance in accordance with that determination.
Closure Date:
6 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction, in consultation with the Office of General Counsel, reviews the Small Business contract to determine what actions should be taken, if any, to recover funds or otherwise address the waste of VA funds.
Closure Date:
7 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the contracting officers’ acceptance of substitute performance that provided no value to VA.
Closure Date:
8 The Assistant Secretary of Human Resources and Administration (HR&A) / Operations, Security, and Preparedness determines what administrative action to take, if any, with respect to the Contracting Officer Representative’s failure to perform diligence sufficient to identify the cloud-computing issues associated with this procurement.
Closure Date:
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| 20-00082-189 | Comprehensive Healthcare Inspection of the Tomah VA Medical Center in Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines the reasons for noncompliance and ensures all staff complete annual suicide prevention refresher training.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are included in the Women Veterans Health Committee charter and attend the quarterly meetings.
Closure Date:
4 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
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| 19-00017-191 | Review of Highly Rural Community-Based Outpatient Clinics' Limited Access to Select Specialty Care | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health completes a specialty care needs assessment for highly rural community-based outpatient clinics to include internet bandwidth and telehealth equipment and develops options for the delivery of safe patient care.
Closure Date:
2 The Under Secretary for Health ensures that the Veterans Health Administration Site Tracking system validation process is completed by each Veterans Integrated Service Network as required and monitors for compliance.
Closure Date:
3 The Under Secretary for Health ensures that facilities and Veterans Integrated Service Networks maintain accurate and current information on websites as required and monitors for compliance.
Closure Date:
4 The Under Secretary for Health completes an assessment to determine whether highly rural community-based outpatient clinics that are located in a non-VA community hospital or health care center are fully utilizing the resources available at the non-VA facilities and takes action as indicated.
Closure Date:
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| 19-09377-192 | Anesthesia Provider Practice Concerns at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates review of the Veterans Health Administration’s credentialing policy to determine the need for requirement clarification related to prior employment history to include applicant listing of locum tenens contracting companies.
Closure Date:
2 The W. G. (Bill) Hefner VA Medical Center Director ensures credentialing and privileging staff verify applicants’ information within the required timeframe outlined by Veterans Health Administration policy and monitors for compliance.
Closure Date:
3 The W. G. (Bill) Hefner VA Medical Center Director ensures annual proficiency reports are completed and maintained consistent with Veterans Health Administration requirements and monitors for compliance.
Closure Date:
4 The W. G. (Bill) Hefner VA Medical Center Director ensures all available performance and competency information is provided to the Professional Standards Board for consideration during provider probationary and reprivileging reviews and monitors for compliance.
Closure Date:
5 The W. G. (Bill) Hefner VA Medical Center Director ensures that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
Closure Date:
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| 19-07543-178 | Inadequate Care by a Clinical Pharmacy Specialist and a Primary Care Provider at the Tennessee Valley Healthcare System in Nashville | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director conducts a comprehensive review of the patient’s care including collaboration among Patient Aligned Care Team members and takes action as indicated.
Closure Date:
2 The Tennessee Valley Healthcare System Director ensures facility staff are aware of and follow Veterans Health Administration Directive 1088, Communicating Test Results to Providers and Patients, specifically the requirement for the ordering clinician to communicate all test results to patients.
Closure Date:
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| 19-09436-185 | Deficiencies in Evaluation, Documentation, and Care Coordination for a Bariatric Surgery Patient at the VA Pittsburgh Healthcare System in Pennsylvania | Hotline Healthcare Inspection | ||
1 The VA Pittsburgh Healthcare System Director considers developing a facility policy for bariatric surgery to include preoperative medical and mental health evaluations.
Closure Date:
2 The VA Pittsburgh Healthcare System Director ensures that bariatric patients receive all preoperative medical and mental health evaluations and monitors compliance.
Closure Date:
3 The VA Pittsburgh Healthcare System Director reviews the documentation error noted in this report and takes action as appropriate.
Closure Date:
4 The VA Pittsburgh Healthcare System Director provides education to staff on how to correct documentation errors and the requirement to follow facility policy.
Closure Date:
5 The VA Pittsburgh Healthcare System Director ensures interdisciplinary discussions about preoperative bariatric patients are documented in the electronic health record and monitors compliance.
Closure Date:
6 The VA Pittsburgh Healthcare System Director considers a programmatic review of the Bariatric Surgery Program to ensure patients receive a comprehensive preoperative evaluation and postoperative follow-up care.
Closure Date:
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| 20-00067-172 | Comprehensive Healthcare Inspection of the Oscar G. Johnson VA Medical Center in Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines the reason(s) for noncompliance and ensures that ongoing professional practice evaluations include service-specific criteria.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Executive Committee minutes consistently reflect the review of professional practice evaluation results.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing for patients prior to initiating or continuing long-term opioid therapy and periodically thereafter.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within the required time frame after initiating long-term opioid therapy.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
Closure Date:
9 The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the VISN Sterile Processing Services Management Board.
Closure Date:
10 The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that include at least two methods of verification for reprocessing reusable medical equipment.
Closure Date:
11 The Associate Director for Patient Care Services evaluates and determines additional reason(s) for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 19-07281-105 | VA Should Examine Options to Expand Retail Pharmacy Drug Discounts | Review | ||
1 The OIG recommended the Under Secretary for Health conduct a formal analysis of VHA’s Office of Community Care prescription drug programs to determine what steps VA would need to take to require drug manufacturers to provide Big 4 prices for covered prescription drugs purchased for CHAMPVA and any other VA Community Care programs that use a retail pharmacy.
Closure Date:
2 The OIG recommended the Under Secretary for Health collaborate with the Office of Regulatory and Administrative Affairs and, if determined appropriate, pursue any proposed statutory or other changes needed to provide VA with the appropriate legal authority to purchase all prescription drugs through retail pharmacies at the Big 4 prices.
Closure Date:
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| 18-06501-158 | Attorney Misconduct, Inadequate Supervision, and Mismanagement in the Office of General Counsel | Administrative Investigation | ||
1 The Acting VA General Counsel confers with the Designated Agency Ethics Official and the Assistant Secretary for Human Resources and Administration to determine whether any remaining administrative action should be taken with respect to the Attorney’s conduct.
Closure Date:
2 The Acting VA General Counsel confers with the Designated Agency Ethics Official to determine whether VA should take any further action with respect to the Attorney’s representation of private parties in matters currently pending in U.S. federal court in which the United States is a party or has a direct and substantial interest to address any other government ethics issues.
Closure Date:
3 The Acting VA General Counsel determines what, if any, obligation the Office of General Counsel has with respect to reporting the Attorney’s conduct to the relevant disciplinary authority under Rule 8.3 of the New York Rules of Professional Conduct or any other governing authority.
Closure Date:
4 The Acting VA General Counsel determines the appropriate action to take, if any, with respect to Mr. Hogan’s failure in his official duties to take appropriate action.
Closure Date:
5 The Acting VA General Counsel determines the appropriate action to take, if any, with respect to the Deputy Chief Counsel’s failure in his official duties to take appropriate action.
Closure Date:
6 The Acting VA General Counsel confers with VA’s Designated Agency Ethics Official to revise its November 8, 2019 memorandum. The revision should at a minimum (a) emphasize all criminal conflict of interest statutes relevant to outside employment, (b) ensure appropriate time for supervisory review of confidential financial disclosure reports to identify potential conflicts or other issues, (c) identify the official responsible for ensuring that the annual risk assessment focused on outside activities is completed on an annual basis to assist Chief Counsel in identifying employees with outside employment, (d) engage employees with outside employment in formal discussions regarding applicable ethical rules and the consequences of noncompliance, and (e) document the annual meetings and formal discussions they have with employees.
Closure Date:
7 The Acting VA General Counsel confers with VA’s Designated Agency Ethics Official to determine whether VA should consider implementing a supplemental agency regulation requiring VA employees, or any category of employees, to disclose and obtain prior approval before engaging in any outside activities for which they receive compensation in accordance with 5 C.F.R. § 2635.803.
Closure Date:
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| 18-06292-117 | Overtime Use in the Office of Community Care to Process Non-VA Care Claims Not Effectively Monitored | Audit | ||
1 The Office of Community Care completes a review of the OIG identified employees who had no claims processing production or activity in the Fee Basis Claims System during overtime hours to determine whether the employees’ conduct requires disciplinary or other corrective action, as appropriate.
Closure Date:
2 The Office of Community Care establishes and implements controls for Payment Operations and Management supervisors to effectively monitor and assess staff productivity during overtime hours to mitigate the risk of overtime abuse.
Closure Date:
3 The Payment Operations and Management directorate clarifies and communicates nurse productivity standards and requirements.
Closure Date:
4 The Payment Operations and Management directorate develops and implements formal guidance for its staff on the appropriate use of overtime, and the controls needed for monitoring compliance.
Closure Date:
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15169