Date Issued
|
Report Number
15-04365-328
All Reports
Date Issued
|
Report Number
16-00327-209
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 6/1/2017
We recommended the Acting Assistant Secretary for Human Resources and Administration assign responsibility to an office to assess hosting solution options for the Dashboard Tool.
No. 2
to Human Resources and Administration Office (HRA),Operations, Security, and Preparedness (OSP)
Closure Date: 5/7/2018
We recommended the Acting Assistant Secretary for Human Resources and Administration evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool investment.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 3,700,000.00
Date Issued
|
Report Number
16-03808-215
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Suicide Prevention Coordinators provide at least five outreach activities per month and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete Suicide Prevention Safety Plans for all high-risk patients, include in the plans the contact numbers of family or friends for support, and give the patient and/or caregiver a copy of the plan, and that facility managers monitor compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians, in consultation with Suicide Prevention Coordinators, identify inpatients as at high risk for suicide, they place Patient Record Flags in the patients' electronic health records and notify the Suicide Prevention Coordinator of each patient's admission, and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that a Suicide Prevention Coordinator or mental health provider evaluates inpatients identified as at high risk for suicide at least four times during the first 30 days after discharge, and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when clinicians identify outpatients as at high risk for suicide, they review the Patient Record Flags every 90 days and document the review and their justification for continuing or discontinuing the Patient Record Flags, and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 7/20/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians complete suicide risk management training within 90 days of hire and that facility managers monitor compliance.
Date Issued
|
Report Number
16-04416-231
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health develop a timeline to reduce improper payments under 10 percent for the VA Community Care and Purchased Long Term Services and Support Programs.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health implement steps to achieve reduction targets for the VA Community Care, Purchased Long Term Services and Support, Beneficiary Travel, Civilian Health and Medical Program of the Department of Veterans Affairs, State Home Per Diem Grants, and Supplies and Materials Programs.
No. 3
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Principal Executive Director, Office of Acquisition, Logistics, and Construction, implement additional training with respect to identifying unauthorized commitments and verifying pricing for personnel who evaluate Improper Payment Elimination and Recovery Act samples for the Supplies and Materials Program.
No. 4
to Veterans Health Administration (VHA),Acquisitions, Logistics, and Construction (OALC),Office of Management (OM)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Acting Secretary for Management and Acting Chief Financial Officer, and the Principal Executive Director, Office of Acquisition, Logistics, and Construction, develop appropriate testing procedures for direct to patient and Federal Supply Schedule contract payments.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Veterans Benefits Administration implement steps to identify and report a reliable improper payment estimate for the Post-9/11 G.I. Bill Program.
No. 6
to Veterans Health Administration (VHA),Office of Management (OM)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Health, in coordination with the Acting Assistant Secretary for Management and Acting Chief Financial Officer, provide the Improper Payment Elimination and Recovery Act team guidance to achieve the expected level of precision for the improper payment estimates for the VA Community Care and Purchased Long Term Services and Support Programs.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Benefits continue working with the Department of Defense to increase the frequency of drill pay adjustments from annually to monthly.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 3/13/2018
We recommended the Acting Under Secretary for Benefits report any statutory barrier preventing complete resolution to drill pay improper payments in its Agency Financial Report.
Date Issued
|
Report Number
16-03807-223
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that for employees who prepare compounded sterile products, facilities include in their competency assessment requirements gloved fingertip sampling and the required number of gloved fingertip samplings for initial competency assessment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities include in the competency assessment checklists of employees who prepare compounded sterile products donning of personal protective equipment in the required order and performance of appropriate hand hygiene after personal protective equipment removal.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure competency assessments for employees who prepare compounded sterile products include gloved fingertip sampling, written tests, and visual observation or “hands-on” skill assessment of aseptic technique at the required risk level frequency.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/9/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure sterile chemotherapy-type gloves are available in areas where hazardous compounded sterile products are prepared.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Acting Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility managers ensure employees clean sterile compounding area floors daily and storage shelving monthly and document the cleaning.
Date Issued
|
Report Number
16-04882-216
Date Issued
|
Report Number
16-03920-197
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/28/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure a medical physicist inspects computed tomography scanners after completion of repairs or modifications that affect the dose or image quality prior to returning the scanners to clinical service.
Date Issued
|
Report Number
17-00976-176
Date Issued
|
Report Number
17-01000-177
Date Issued
|
Report Number
15-05379-146
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health update patient advocate policies and procedures to ensure they meet current needs.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health develop procedures to ensure pertinent program information is recorded in a standardized format in the Patient Advocate Tracking System.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/5/2018
We recommended the Under Secretary for Health ensure responsible officials and staff perform patient complaint processing activities in accordance with policies and procedures, such as assuring required program information is recorded and trended at the local and national level.
No. 4
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health work with the Assistant Secretary for Information and Technology to ensure its Patient Advocate Tracking System meets current program requirements for efficient complaint processing and reporting.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 8/17/2021
We recommended the Under Secretary for Health establish controls to ensure that patient advocate staffing levels are sufficient to support patient advocate workload estimates.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/21/2017
We recommended the Under Secretary for Health provide patient advocates with periodic formal documented training concerning their responsibilities and utilizing the Patient Advocate Tracking System.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 6/5/2018
We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to the Patient Advocate Tracking System are regularly reviewed and extended based upon specific job duties and the need to know.
No. 8
to Veterans Health Administration (VHA),Information and Technology (OIT)
Closure Date: 9/19/2017
We recommended the Assistant Secretary for Information and Technology work with the Under Secretary for Health to fully assess the Patient Advocate Tracking System security and operational risks and to initiate appropriate corrective actions, including requesting the authority to operate the Patient Advocate Tracking System, if appropriate.
Date Issued
|
Report Number
16-03743-193
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/29/2019
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure clinical managers evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency required by facility policy.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/9/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers and facility senior managers, ensure clinical managers implement the improvement actions recommended by the Peer Review Committee.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Utilization Managers complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors document their review decisions in the Veterans Health Administration’s utilization management database.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Patient Safety Managers enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 6/18/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure committees and teams consistently implement and evaluate corrective actions from quality, safety, and value activities.
Date Issued
|
Report Number
16-00252-137
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/9/2017
We recommended the Under Secretary for Health recover the reported improper payments for outpatient services that could not have been rendered to deceased veterans.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/9/2017
We recommended the Under Secretary for Health ensure medical facilities adhere to VHA Procedure Guide 1601F.02 and update non-VA care authorization end dates for deceased veterans.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 505,000.00
Date Issued
|
Report Number
16-03985-181
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended that the Under Secretary for Health implement an automated transcription function for callers’ phone numbers in the Veterans Crisis Line call documentation recording system.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure that Veterans Crisis Line policies and procedures, staff education, Information Technology support, and monitoring are in place for audio call recording.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health implement a Veterans Crisis Line governance structure that ensures cooperation and collaboration between VHA Member Services and the Office of Suicide Prevention.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health develop clear guidelines that delineate clinical and administrative decision-making, assuring that clinical staff make decisions directly affecting clinical care of veterans in accordance with sound clinical practice.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended that the Under Secretary for Health ensure processes are in place for routinely reviewing backup center data, establish wait-time targets for call queuing and rollover, and ensure plans are in place for corrective action when wait-time targets are exceeded.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 11/8/2017
We recommended that the Under Secretary for Health ensure processes are in place to require contracted backup centers to have the same standards as the Veterans Crisis Line related to call queuing and wait-time targets.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure that VHA Member Services leadership, Veterans Crisis Line leadership, VHA Contracting Officers, and Contracting Officer Representatives implement the quality control plan and conduct ongoing oversight to ensure contractor accountability in accordance with their roles as specified in the contract with backup call centers.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 11/8/2017
We recommended that the Under Secretary for Health ensure that training is provided to Veterans Crisis Line quality management staff in the skills needed to provide leadership to promote quality and safety of care.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure the development of structured oversight processes for tracking, trending, and reporting of clinical quality performance measures.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure processes for Veterans Crisis Line quality management staff to collect and review adverse outcomes so that established cohorts of severe adverse outcomes are analyzed.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health direct the Veterans Health Administration Assistant Deputy Under Secretary for Health for Quality, Safety, and Value to review existing Veterans Crisis Line policies and determine whether the policies incorporate the appropriate Veterans Health Administration policies for veteran safety and risk management, and if not, establish appropriate action plans.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 11/8/2017
We recommended that the Under Secretary for Health ensure that Veterans Crisis Line quality management staff incorporate call audio recording into quality management data analysis.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 7/25/2017
We recommended that the Under Secretary for Health ensure that processes are in place to analyze performance and quality data from the Atlanta Call Center separately from the Canandaigua Call Center data.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 3/28/2018
We recommended that the Under Secretary for Health ensure that quality assurance monitoring policies and procedures are in place and consistent for both Social Service Assistants and responders.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure that supervisors certify Social Service Assistant training prior to engaging in independent assistance with rescues.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 2/28/2018
We recommended that the Under Secretary for Health ensure a process is in place to establish, maintain, distribute, and educate staff on all Veterans Crisis Line policies and directives that includes verifying the use of current versions when policies and directives are modified.
Date Issued
|
Report Number
16-03805-20
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities revise discharge policies to include encouraging physicians to schedule discharges early in the day.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/3/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities develop or revise policies addressing overflow patients in temporary bed locations and include priority placement for inpatient beds given to patients in temporary bed locations, upholding standard of care while patients are in temporary bed locations, medication administration, and meal provision.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 7/2/2018
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when resident physicians complete discharge notes or instructions, supervising physicians co-sign the residents’ notes.
Date Issued
|
Report Number
16-02138-149
Date Issued
|
Report Number
15-04925-469
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/21/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinical staff offer HIV screening as part of routine medical care and that managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 7/18/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians document informed consent for HIV testing and that managers monitor for compliance.
VA Office
Date Issued
|
Report Number
15-01436-456
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/27/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, review the improper payments identified in this report and take appropriate corrective actions when warranted.
No. 2
to Veterans Benefits Administration (VBA)
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, strengthen controls to ensure intended recipients meet entitlement requirements before authorizing automated burial payments.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/8/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with the requirement under the United States Code of Federal Regulations that proof of death be submitted prior to the release of automated burial payments.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 9/27/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, initiate action to ensure policies and procedures are consistent with United States Code of Federal Regulations related to automated burial payments and recipients’ entitlement requirements prior to authorizing payments.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 6/13/2017
We recommended the Principal Deputy Under Secretary for Benefits, Performing the Duties of Under Secretary for Benefits, ensure quality assurance reviews determine whether staff inappropriately discontinued veterans’ disability benefits and assess whether spouses met entitlement requirements to receive automated burial payments.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 28,000,000.00
Date Issued
|
Report Number
15-02189-336
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology implement improved controls to ensure the effective oversight of information technology projects and compliance with information technology project management procedures in order to ensure delivery of value.
No. 2
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology enforce the use of the Project Management Accountability System or Veteran-focused Integration Process on all Office of Information and Technology software development projects to ensure that such efforts will provide an adequate return on investment.
No. 3
to Information and Technology (OIT)
Closure Date: 5/1/2017
We recommended the Assistant Secretary for Information and Technology establish oversight mechanisms to ensure all VA-developed software costs are funded with Information Technology Systems appropriations.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,300,000.00
Date Issued
|
Report Number
14-04097-139
Date Issued
|
Report Number
15-04673-333
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended the Under Secretary for Health streamline processes and procedures for accessing care under the Veterans Choice Program.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/7/2019
We recommended the Under Secretary for Health develop accurate forecasts of demand for care purchased in the community.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 8/14/2017
We recommended the Under Secretary for Health simplify requirements for network providers to bill for services under the Veterans Choice Program.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/1/2018
We recommended the Under Secretary for Health ensure eligible veterans are not financially liable for the full cost of treatment authorized under the Veterans Choice Program.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 10/2/2018
We recommended the Under Secretary of Health ensure community providers are paid in a timely manner under the Veterans Choice Program.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/14/2017
We recommended the Under Secretary for Health review the Veterans Choice Program to determine if growth of provider networks is being limited by allowing reimbursement below Medicare rates.