Recommendations
2080
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00013-15 | Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center, Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors manager compliance.
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2 The chief of staff ensures that final peer reviews are completed within 120 calendar days from the determination of the need for the review, or there is an extension approved in writing by the director, and monitors compliance.
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3 The facility director makes certain that a summary of the Peer Review Committee’s work is reviewed quarterly by the executive level medical committee and monitors compliance.
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4 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
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5 The chief of staff makes certain that service chiefs define and communicate expectations for focused professional practice evaluation criteria in advance and maintain appropriate documentation of the processes and monitors service chiefs’ compliance.
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6 The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
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7 The associate director ensures a clean and safe environment is maintained throughout the facility and monitors team’s compliance.
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8 The associate director ensures the facility maintains an inventory of assets and resources available in the event of a disaster and that it is reviewed annually and monitors compliance.
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9 The associate director validates that the facility’s emergency operations plan includes all required elements and is reviewed annually and monitors compliance.
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10 The facility director makes certain that the controlled substances coordinator submits monthly summary of findings and quarterly trends, that include discrepancies and vulnerabilities, to the director and monitors controlled substances coordinator’s compliance.
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11 The facility director makes certain that the appropriate quality management committee reviews the controlled substances monthly and quarterly reports at least on a quarterly basis and monitors compliance.
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12 The facility director makes certain the controlled substances coordinator conducts required annual competency assessments of the controlled substances inspectors and monitors the coordinator’s compliance.
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13 The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substances in storage areas on the day initiated and monitors inspectors’ compliance.
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14 The facility director makes certain that reconciliation of one day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during monthly controlled substances area inspections and monitors compliance.
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15 The facility director makes certain the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substances orders during monthly area inspections and monitors compliance.
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16 The facility director makes certain that controlled substances inspectors verify, during monthly inspections, there is a corresponding sealed evidence bag containing drug(s) for each destruction holding number listed on the “Destructions File Holding Report” and monitors inspector’s compliance.
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17 The facility director ensures that controlled substances inspectors complete verification of prescription pad inventories count during monthly pharmacy inspections and monitors inspectors’ compliance.
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18 The facility director ensures that the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances prescriptions during monthly area inspections and monitors inspectors’ compliance.
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19 The facility director makes certain that controlled substances inspectors complete the verification of the 72-hour inventory and monitors inspectors’ compliance.
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20 The chief of staff ensures providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
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21 The facility director confirms that the committee responsible for Women Veterans Subcommittee meets quarterly and includes required core members and monitors committee’s compliance.
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22 The facility director ensures that assigned staff implement a process to track and follow-up on findings from cervical cancer screenings and monitors staff’s compliance.
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23 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
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24 The chief of staff ensures that a backup call schedule is maintained for emergency department providers and monitors the department’s compliance.
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| 18-06294-213 | VHA Did Not Effectively Manage Appeals of Non VA Care Claims | Audit | ||
1 The Under Secretary for Health ensure the Payment Operations and Management directorate identifies its facilities that receive appeals but do not have sufficient staff assigned to process them, and then promptly transfers unprocessed appeals from those facilities to a Payment Operations and Management appeals-processing facility to ensure they are processed.
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2 The Under Secretary for Health ensure the Payment Operations and Management directorate updates communications to direct claimants to submit appeals to its facilities with designated appeals-processing staff.
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3 The Under Secretary for Health clearly define the roles and responsibilities of an accountable OCC official to oversee the Payment Operations and Management directorate’s appeals function.
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4 The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates effective policies and procedures for its staff to promptly process their pending appeals workload.
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5 The Under Secretary for Health ensure the Payment Operations and Management directorate completely and accurately identifies and records its pending appeals inventory in a standard system of record and implements controls to effectively maintain the pending appeals inventory in the system of record.
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6 The Under Secretary for Health ensure all Payment Operations and Management directorate appeals processors obtain access to Caseflow promptly, and that Caseflow includes fields that are necessary to effectively manage Payment Operations and Management appeals.
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7 The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates to all staff effective policies and procedures for processing and managing appeals under the new appeals process, including timeliness standards.
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8 The Under Secretary for Health ensure the Payment Operations and Management directorate completes a comprehensive assessment of its appeals workforce and inventory, and then reevaluates its appeals staffing needs.
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| 18-04675-23 | Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System, West Haven, Connecticut | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that service chiefs clearly define and share in advance the expectations for the focused professional practice evaluation process with providers and monitors the service chiefs’ compliance.
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2 The chief of staff ensures that service chiefs include service/section-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
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3 The chief of staff ensures that service chiefs’ determination to continue current privileges is based, in part, on results of ongoing professional practice evaluation activities and monitors service chiefs’ compliance.
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4 The facility director ensures that the Medical Staff Executive Council documents consideration of focused and ongoing professional practice evaluation results in its decision to recommend approval of requested privileges and monitors the Medical Staff Executive Council’s compliance.
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5 The facility director makes certain that an adequate number of controlled substances inspectors are appointed in writing prior to performing inspector duties to a term not to exceed three years and monitors the compliance.
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6 The facility director ensures that a controlled substances inspector does not inspect the same controlled substances area for two consecutive months and monitors inspectors’ compliance.
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7 The facility director ensures that monthly reconciliation of one-day’s dispensing from pharmacy to every automated dispensing cabinet and one-day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
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8 The facility director ensures that the controlled substances coordinator refrains from conducting routine inspections of controlled substance storage areas and monitors inspector’s compliance.
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9 The facility director makes certain that the nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff’s compliance.
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10 The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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11 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and assess understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
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12 The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
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13 The chief of staff ensures providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.
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| 19-00075-14 | Deficiencies in Sterile Processing Services and Decreased Surgical Volume at the VA Connecticut Healthcare System, Newington and West Haven, Connecticut | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 1 Director provides oversight for the timely implementation of Office of Inspector General recommendations directed to the VA Connecticut Healthcare System Director.
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2 The Veterans Integrated Service Network 1 Director ensures the timely completion of hiring actions at the VA Connecticut Healthcare System until staffing deficiencies in Sterile Processing Services and Facility Management Services are fully resolved.
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3 The VA Connecticut Healthcare System Director ensures clinical leaders with working knowledge of and/or expertise in operating room, surgery, and Sterile Processing Services are included in the decision-making and resolution of Sterile Processing Service remediation efforts.
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4 The VA Connecticut Healthcare System Director ensures the development and implementation of a clear action plan to establish communication, foster collaboration, and restore system staff trust in system leaders, and, as necessary, consult with Veterans Health Administration’s National Center for Organizational Development.
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5 The VA Connecticut Healthcare System Director provides oversight for the timely completion of the projects impacting Sterile Processing Services and Surgical Services that remain pending.
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6 The VA Connecticut Healthcare System Director ensures that the development, review, and revision of standard operating procedures is completed, and that a sustainable process is in place to maintain standard operating procedures.
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7 The VA Connecticut Healthcare System Director ensures that all Sterile Processing Services staff complete and maintain Sterile Processing Services training and competencies.
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8 The VA Connecticut Healthcare System Director ensures that Sterile Processing Services leaders maintain a staffing plan that includes an accurate number of authorized positions that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
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9 The VA Connecticut Healthcare System Director ensures that surgery and anesthesia staff evaluate the readiness of all supplies and equipment for use before anesthetizing a patient.
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10 The VA Connecticut Healthcare System Director evaluates and reports the impact on and identified needs of the VA Connecticut Healthcare System residency program.
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11 The VA Connecticut Healthcare System Director works collaboratively with Veterans Integrated Service Network 1 Director to ensure the timely implementation of future Sterile Processing Services planned projects.
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| 19-00002-16 | Two Patient Suicides, a Patient Self-Harm Event, and Mental Health Services Administrative Deficiencies at the Alaska VA Healthcare System, Anchorage, Alaska | Hotline Healthcare Inspection | ||
1 The Alaska VA Healthcare System Director ensures that staff are educated and trained on missing patient policies and procedures, and monitors compliance.
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2 The Alaska VA Healthcare System Director makes certain that managers establish a unified Same Day Access Clinic policy, educates staff on the policy, and monitors compliance.
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3 The Alaska VA Healthcare System Director ensures a psychiatric coverage plan for the Same Day Access Clinic for all hours of operation that includes a contingency plan for psychiatric providers’ unavailability.
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4 The Alaska VA Healthcare System Director establishes clearly defined Same Day Access Clinic hours that are consistent with the Same Day Access Clinic policy and signage.
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5 The Northwest Network Director strengthens the Alaska VA Healthcare System leaders’ adherence to the scheduling directive reporting structure as required by the Veterans Health Administration.
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6 The Alaska VA Healthcare System Director implements standardized clinically indicated date and return to clinic order procedures, and staff training, and monitors for compliance.
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7 The Alaska VA Healthcare System Director establishes a missed appointment policy, ensures that staff are educated on the policy, and monitors compliance.
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8 The Alaska VA Healthcare System Director facilitates the full implementation of a Behavioral Health Interdisciplinary Program, as required by the Veterans Health Administration.
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9 The Alaska VA Healthcare System Director ensures staff training on the Mental Health Treatment Coordinator policy established on February 1, 2019, and monitors compliance.
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10 The Alaska VA Healthcare System Director establishes a behavioral health emergency policy, ensures that staff are educated on the policy, and monitors compliance.
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11 The Northwest Network Director ensures that the Alaska VA Healthcare System Director evaluates the culture, morale, and leadership issues identified by the alternative dispute resolution specialist in this report and takes appropriate action as necessary.
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| 19-00011-255 | Comprehensive Healthcare Inspection of the James A. Haley Veterans' Hospital, Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
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2 The chief of staff ensures that service chiefs clearly define and share in advance the expectations, outcomes, and time limits for focused professional practice evaluations for cause with providers and monitors service chiefs’ compliance.
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3 The facility director makes certain that the pharmacy or nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff compliance
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4 The facility director confirms providers complete military sexual trauma mandatory training no later than 90 days after assuming their position and monitors providers’ compliance.
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5 The chief of staff ensures that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and assess understanding of the education provided and monitors clinicians’ compliance.
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6 The chief of staff ensures clinicians reconcile medication information and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors the clinicians’ compliance.
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7 The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
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| 19-05960-244 | Records Management Center Disclosed Third-Party Personally Identifiable Information to Privacy Act Requesters | Review | ||
1 The Under Secretary for Benefits implements the Veterans Benefits Administration’s commitment to update its Privacy Act release policy and begin redacting third-party personally identifiable information.
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2 The Under Secretary for Benefits ensures VA’s website is updated to reflect current Veterans Benefits Administration policy regarding release of third-party personally identifiable information.
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3 The Under Secretary for Benefits implements a plan to ensure the Records Management Center complies with requirements for mailing Privacy Act responses in accordance with VA Directive 6609.
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4 The Under Secretary for Benefits establishes a plan to ensure that Records Management Center management receives a report for any site visit of the Records Management Center completed by the Veterans Benefits Administration and takes corrective action as needed.
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5 The Records Management Center director implements a plan to improve quality reviews and ensures staff are held accountable for the accuracy of their Privacy Act releases.
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| 18-04682-256 | Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center, Dublin, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
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2 The facility director ensures the patient safety manager includes all required content in each root cause analysis and monitors patient safety manager’s compliance.
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3 The director ensures the Intensive Care Unit/Cardiopulmonary Resuscitation Committee conducts a complete analysis of resuscitative episodes that includes all required elements and monitors committee’s compliance.
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4 The chief of staff ensures that service chiefs define and communicate expectations for focused professional practice evaluations in advance and maintain appropriate documentation of the process and monitors service chiefs’ compliance.
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5 The chief of staff makes certain that the service chiefs document the focus professional practice evaluation results in the practitioner profiles and monitors service chiefs’ compliance.
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6 The chief of staff ensures that service chiefs include the minimum-required specialty-specific criteria for professional practice evaluations of gastroenterology and nuclear medicine practitioners and monitors service chiefs’ compliance.
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7 The chief of staff ensures that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
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8 The chief of staff makes certain that the Medical Executive Committee documents its decision to recommend privileges based on professional practice evaluation results when recommending approval of privileges to the director and monitors committee’s compliance.
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9 The facility director reports privileging actions taken by the facility to the National Practitioner Data Bank and monitors compliance.
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10 The associate director ensures that the VA Police regularly test panic alarms and document results and monitors staff compliance.
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11 The facility director makes certain that controlled substances program staff reconcile one day’s stocking/refilling from the pharmacy to each dispensing area and one day’s return of stock to pharmacy from every automated dispensing unit during monthly inspections and monitors coordinator’s compliance.
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12 The facility director confirms that the controlled substances coordinator ensures that written and electronic controlled substance orders have been verified and assessed for documentation of two signatures for any waste of partial doses and monitors coordinator’s compliance.
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13 The facility director makes certain that the controlled substances coordinator validates that monthly inventories of controlled substances are conducted as required in the pharmacy and monitors coordinator’s compliance.
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14 The facility director ensures the development and implementation of a policy for automated dispensing cabinet medication overrides and reviews of these reports and monitors compliance.
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15 The chief of staff confirms that the military sexual trauma coordinator communicates the status of military sexual trauma-related issues, services, and initiatives to facility leadership and monitors coordinator’s compliance.
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16 The chief of staff confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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17 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
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18 The facility director ensures the appointment of a women’s health medical director or clinical champion.
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19 The facility director ensures the facility has a Women Veterans Health Committee that has an active charter, meets at least quarterly, and reports to leadership with signed minutes and monitors committee’s compliance.
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20 The facility director makes certain that facility staff implement a process to track and monitor cervical cancer screenings, results reporting, and follow-up care and monitors assigned staff compliance.
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21 The chief of staff ensures patient notification of abnormal cervical results are completed within the required time frame and monitors compliance.
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22 The chief of staff makes certain that a backup call schedule is maintained for urgent care center providers and monitors compliance.
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| 19-07247-251 | FY 2019 Audit of VA’s Compliance under the DATA Act of 2014 | Audit | ||
1 We recommend the Assistant Secretary for Management and Chief Financial Officer 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. Store 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). The reconciliations should be performed prior to the quarterly certification.
c. Report reconciliation with its subsidiary systems.
d. A mechanism to ensure transactions are reported that currently may be excluded due to the use of 1358s.
e. Standardize data field use to allow for management to record an award ID across financial and supporting systems.
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2 We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure a DQP is finalized and implemented for future DATA Act submissions which meets the requirements for DATA Act reporting. In addition, the Office of Management, Office of Internal Control, and the Office of Enterprise Risk Management should ensure that the DQP supports the annual assurance statement and quarterly certification.
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3 We recommend the Assistant Secretary for Management and Chief Financial Officer Implement a grants management solution that will be either integrated with the new financial system or interface into it once completed. The VA should identify a grants management solution that can be implemented across all of VA’s grant programs.
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4 We recommend the Assistant Secretary for Management and Chief Financial Officer Work with the SAO and component level SAO’s to ensure that all certifications are signed, dated by the component SAO and received prior to the submission date.
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5 We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure that the four CFDA programs (64.014, 64.015, 64.026, and 64.024) report obligations according to the definitions established for FABS reporting or obtain OMB and Treasury’s approval for any deviations.
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6 We recommend the Assistant Secretary for Management and Chief Financial Officer Ensure the Office of Budget implements monitoring controls over CFDA numbers to ensure any CFDA numbers that require activation are identified and activated promptly to avoid interruptions in expenditure reporting.
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7 We recommend the Assistant Secretary for Management and Chief Financial Officer Research the basis for the delays in reporting expenditure data for FABS for the VHA Veterans Prescription Service program (CFDA # 64.012) and implement a corrective action plan for timely reporting going forward. The VA PMO should also seek an exemption from OMB and Treasury regarding the reporting delays for the program if no viable solutions are identified to mitigate the timing delays.
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8 We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain and document guidance from Treasury and OMB on the proper treatment of payments to contractors for VA’s Veterans Choice Program as either contract award (File D1) or financial assistance (File D2).
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9 We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain and document guidance from Treasury and OMB regarding inclusion of payroll and contract costs in the FABS (File D2) and the duplication of the same contract costs in the FPDS-NG (File D1).
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10 We recommend the Assistant Secretary for Management and Chief Financial Officer Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for FABS 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 sub certification.
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. Support from Treasury and OMB on the proper reporting of face amount of insurance in its FABS submissions.
d. The information submitted for each data element is adequately supported and readily available.
e. All data elements are reported in compliance with the definitions established by the DAIMS.
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11 We recommend the Assistant Secretary for Management and Chief Financial Officer Improve review procedures prior to submission to identify errors and ensure all transactions are included in procurement and financial assistance data.
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12 We recommend the Assistant Secretary for Management and Chief Financial Officer Perform research to determine the extent to which 1358 transactions are not reported for File D1 and develop solutions.
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13 We recommend the Assistant Secretary for Management and Chief Financial Officer Develop solutions and continue system modernization efforts to reduce the use of the default object class. Research and develop program activity crosswalk for medical services.
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14 We recommend the Assistant Secretary for Management and Chief Financial Officer Strengthen procedures over the process to report all program activity names and program activity codes that are reported in the quarterly OMB MAX Collect Exercise in accordance with the latest Budget Data request requirements.
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15 We recommend the Assistant Secretary for Management and Chief Financial Officer Reinforce guidance for Contracting Officers concerning areas where exceptions were noted in DATA Act reporting.
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16 We recommend the Assistant Secretary for Management and Chief Financial Officer Obtain OMB and Treasury approval for aggregating and reporting transactions based on beneficiary address. Ensure controls around the aggregation process are implemented and operating effectively.
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| 19-07095-253 | Ophthalmology Equipment and Related Concerns at the James A. Haley Veterans’ Hospital, Tampa, Florida | Hotline Healthcare Inspection | ||
1 The James A. Haley Veterans’ Hospital Director ensures that Biomedical Section staff complete work order documentation accurately as required by facility policy and in accordance with Veterans Health Administration guidelines.
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2 The James A. Haley Veterans’ Hospital Director enhances efforts to improve equipment corrective maintenance completion times and that Biomedical Section staff communicate the status of repairs with end users.
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3 The James A. Haley Veterans’ Hospital Director takes action to improve the timeliness of eyeglass purchase order processing.
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4 The James A. Haley Veterans’ Hospital Director ensures that Prosthetics and Sensory Aid Service resolves the open eyeglass purchase order requests.
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