Date Issued
|
Report Number
15-02101-143
All Reports
Date Issued
|
Report Number
14-05132-90
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facility policy addresses outpatient pressure ulcer prevention and treatment.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish pressure ulcer committees with appropriate professional representation.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities' pressure ulcer programs define requirements for employee training regarding pressure ulcer risk assessment, skin assessment and management, and documentation of skin assessment findings and that facility managers monitor compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians revise pressure ulcer prevention plans when patients' risk levels change and that facility managers monitor compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document patient/caregiver pressure ulcer education and that facility managers monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians provide and document skin inspections and Braden scales daily during hospitalization, including the day of discharge, and that facility managers monitor compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that facilities establish processes to monitor consistency in documentation of pressure ulcer stage, location, date acquired, and risk scale score and take appropriate actions to address inconsistencies.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 7/7/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that clinicians document wound care follow-up plans for patients discharged with unhealed pressure ulcers and that the facility provides needed supplies.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 3/10/2016
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensure that employees secure medications stored in patients' rooms.
Date Issued
|
Report Number
15-00430-103
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/15/2015
We recommended that the Interim Under Secretary for Health continue to develop and implement staffing models for critical need occupations.
Date Issued
|
Report Number
13-03324-85
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 3/31/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, establish procedures to ensure the Office of Product Development completes all required Planning Reviews (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 2
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure personnel performing Compliance Reviews assess the accuracy and reasonableness of cost information reported on the Project Management Accountability System Dashboard (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 3
to Information and Technology (OIT)
Closure Date: 3/20/2018
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure hiring actions are completed by acquiring the vacant Federal employee positions in the Project Management Accountability System Business Office (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 4
to Information and Technology (OIT)
Closure Date: 1/22/2015
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, not exercise future options of the task order used to augment Project Management Accountability System Business Office staffing once hiring actions have been completed.
No. 5
to Information and Technology (OIT)
Closure Date: 3/31/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete modification of the Project Management Accountability System Dashboard so that it maintains a complete audit trail of baseline data by including planned, revised, and actual figures for project life-cycle and increment costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 6
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, complete development and implementation of a sound methodology to capture and report planned and actual total project and increment level costs (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 7
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, ensure project managers capture and report reliable cost data and maintain adequate audit trails to support how the cost information reported on the Project Management Accountability System Dashboard was derived in the interim until actions to automate budget traceability and shift VA’s IT projects to increment-based contracts are completed (repeat recommendation from the 2011 VA Office of Inspector General audit report).
No. 8
to Information and Technology (OIT)
Closure Date: 9/18/2017
We recommended the Executive in Charge and Chief Information Officer, Office of Information and Technology, clearly define the term “enhancement of an existing system or its infrastructure” and require Service Delivery and Engineering project teams to track and report costs associated with enhancements on the Project Management Accountability System Dashboard.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,400,000.00
Date Issued
|
Report Number
14-04705-62
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/15/2015
We recommended that the Interim Under Secretary for Health conduct a systematic assessment of the processes each VA medical facility used to address unresolved consults during VHA's system-wide consult review.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/13/2015
We recommended that the Interim Under Secretary for Health ensure that if a medical facility's processes are found to have been inconsistent with VHA guidance on addressing unresolved consults, action is taken to confirm that patients have received appropriate care.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/13/2015
We recommended that after reviewing the circumstances of any inappropriate resolution of consults, the Interim Under Secretary for Health confer with the Office of Human Resources and the Office of General Counsel or other relevant agency to determine the appropriate administrative action to take, if any.
Date Issued
|
Report Number
12-02387-59
Date Issued
|
Report Number
13-01545-11
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs limit future use of time and materials contracts to those instances where the extent or duration of the work cannot be anticipated with any reasonable degree of confidence.
No. 2
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that significant new contract requirements are solicited in lieu of merely modifying existing contracts to meet new needs.
No. 3
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs ensure that contractor billings are approved based on sufficient documentation to demonstrate that contractors are meeting performance-based requirements.
No. 4
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs implement improved oversight of contractor activities to ensure they are appropriate to meet contract terms and do not include inherently Governmental functions.
No. 5
to Veterans Health Administration (VHA)
We recommended the Assistant Secretary for the Office of Public and Intergovernmental Affairs develop and implement program performance metrics to determine whether outreach and awareness campaigns are improving veterans’ awareness of and access to VA services and benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 5,000,000.00
Date Issued
|
Report Number
12-02576-30
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health implement a quality assurance program that provides sufficient oversight to ensure that contracting issues are corrected by the responsible contracting office.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health implement a mechanism to facilitate and ensure contracting officers’ performance can be objectively evaluated against their performance standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health monitor contracting officer performance deficiencies and ensure training is provided to correct identified deficiencies.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/22/2016
We recommended the Interim Under Secretary for Health ensure contracting staff complete Integrated Oversight Process reviews in accordance with established policies and contracting officers’ performance standards.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/28/2016
We recommended the Interim Under Secretary for Health revise Integrated Oversight Process review procedures to include a review to ensure Advisory and Assistance services are identified and approved.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended the Interim Under Secretary for Health ensure that contracting officers delegate in writing contracting officers’ representatives requirements and authorities to monitor contracts, as required by Federal and VA acquisition policy and contracting officers’ performance standards.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/24/2015
We recommended the Interim Under Secretary for Health ensure that contracting officers conduct and document quarterly meetings with contracting officers’ representatives as required by VA acquisition policy.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 795,000,000.00
Date Issued
|
Report Number
14-01504-32
Date Issued
|
Report Number
13-01408-294
Date Issued
|
Report Number
14-02198-284
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/16/2016
We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying ordering providers of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/4/2015
We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying women veterans of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
Date Issued
|
Report Number
14-00727-239
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/29/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that at least the minimum required Palliative Care Consult Team staffing is provided.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/20/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensures that end-of-life care training is provided to staff who work in areas where they are likely to encounter patients at the end of their lives.
Date Issued
|
Report Number
14-01785-184
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that pharmacy physical security surveys are conducted and identified deficiencies are corrected and that compliance is monitored.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that quarterly controlled substances inspection trend reports of identified discrepancies, problematic trends, and potential areas for improvement are completed and provided to facility Directors.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that monthly inspections of all non-pharmacy controlled substances areas are conducted and that compliance is monitored.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health ensures that VHA defines in policy acceptable reasons for missed controlled substances area inspections and provides guidance regarding Controlled Substances Coordinator performance of monthly inspections.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate 2 transfers of controlled substances from one storage area to another area, reconcile 1 day’s dispensing from the pharmacy to each automated unit, and verify electronic or written orders for 5 randomly selected dispensing activities.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in
conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors perform quarterly physical counts of the emergency drug cache and monthly verifications of seals and that compliance is monitored.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate completion of all required drug destruction activities.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors validate accountability for all prescription pads stored in the pharmacy.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors conducting outpatient pharmacy inspections verify written prescriptions for 10 percent of (or a maximum of 50) schedule II drugs dispensed.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 12/10/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that controlled substances inspectors receive annual training regarding problematic issues identified through external surveys and other quality control measures.
Date Issued
|
Report Number
13-02129-177
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2017
We recommended the Under Secretary for Benefits take measures to ensure drill pay offsets identified after fiscal year 2012 are timely processed.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/6/2017
We recommended the Under Secretary for Benefits ensure fiscal years 2011 and 2012 drill pay offsets are processed.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 1/5/2017
We recommended the Under Secretary for Benefits modify existing information technology systems to more effectively monitor, track, and report on drill pay offset activities.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 7/23/2015
We recommended the Under Secretary for Benefits update the cost-benefit analysis regularly and use it to prioritize the processing of drill pay offsets.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 12/5/2014
We recommended the Under Secretary for Benefits require Systematic Analysis of Operations be completed annually for drill pay matching activities.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 623,100,000.00
Date Issued
|
Report Number
13-00991-154
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Office of Management (OM)
Closure Date: 2/24/2015
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, review FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold and submit identified unauthorized commitments to Heads of Contracting Activities for ratification actions.
No. 2
to Office of Management (OM)
Closure Date: 10/22/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, establish policies and procedures to perform recurring reviews of purchase card transactions above the micro-purchase threshold to identify transactions made by cardholders without appropriate warrant authority.
No. 3
to Office of Management (OM)
Closure Date: 5/21/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, revise policies and procedures to verify that purchase card spending limits do not exceed warrant authority limits before issuing individuals purchase cards with spending limits above the micro-purchase threshold.
No. 4
to Office of Management (OM)
Closure Date: 5/21/2014
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, require recurring unauthorized commitment training for purchase cardholders and their approving officials.
No. 5
to Office of Management (OM)
Closure Date: 1/12/2015
We recommended the Executive in Charge, Office of Management and Chief Financial Officer, ensure the Management Quality Assurance Service follow-up on the status of ratification of identified unauthorized commitments.
No. 6
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 4/7/2015
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, direct Heads of Contracting Activities to perform individual ratification actions for unauthorized commitments identified by the Executive in Charge, Office of Management and Chief Financial Officer’s review of FYs 2012 and 2013 purchase card transactions above the micro-purchase threshold.
No. 7
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/16/2015
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, create and maintain an accurate database of warranted VA contracting officers that includes warrant effective and expiration dates, and specific warrant authority limitations.
No. 8
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/26/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, establish policies and procedures requiring Heads of Contracting Activities to complete ratification actions within a specified time period after the identification of unauthorized commitments.
No. 9
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 11/26/2014
We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction, limit institutional ratifications by ensuring every unauthorized commitment meets the ratification review requirements.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 85,600,000.00
Date Issued
|
Report Number
14-00895-163
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/13/2014
We recommended that the Under Secretary for Health ensure that the practice of prescribing acetaminophen is in compliance with acceptable standards.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/18/2015
We recommended that the Under Secretary for Health ensure that VA's practice of routine and random urine drug tests prior to initiating and during take-home opioid therapy to confirm the appropriate use of opioids is in alignment with acceptable standards.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that follow-up evaluations of patients on take-home opioids are performed timely.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that opioid patients with active (not in remission) substance use receive treatment for substance use concurrently with urine drug tests.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/30/2015
We recommended that the Under Secretary for Health ensure that VA's practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with acceptable standards.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/28/2015
We recommended that the Under Secretary for Health ensure that medication reconciliation is performed to prevent adverse drug interactions.
Date Issued
|
Report Number
13-00054-148
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that completed improvement actions related to protected peer review are reported to the Peer Review Committee.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facility observation bed processes are guided by comprehensive policies and that usage is monitored.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that reviews of inpatients’ continuing stays are consistently completed.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ scanning processes are guided by comprehensive policies, that medical information is properly scanned into patients’ electronic health records, and that compliance is monitored.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/18/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for thorough review of individual resuscitation episodes.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 10/7/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensures that facilities’ transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
Date Issued
|
Report Number
14-01072-140
Date Issued
|
Report Number
14-01073-139
Date Issued
|
Report Number
14-01288-145
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that inspections are completed at the designated frequency and by required members, that all required elements are documented, and that construction sites comply with applicable VA and Occupational Safety and Health Administration requirements.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that contractor tuberculosis risk assessments are conducted.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that facilities establish Construction Safety Committees; develop and implement written policies addressing committee responsibilities; assure required committee membership and participation; and ensure meeting minutes include consistent documentation of inspection results, follow-up actions to resolve unsafe conditions, and tracking of actions to completion.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/27/2015
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that Infection Control Committee meeting minutes include consistent documentation of construction-related infection control surveillance activities and any necessary follow-up actions to identified trends or problems.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 11/12/2014
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility leaders, ensures that designated facility staff receive required initial and biennial construction safety training.