All Reports

We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders receive, review, and approve psychosocial assessments and counseling plans prior to authorizing contracted counseling services.

We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct and document client assessments after 1 year of eligibility for contracted client services.

We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders conduct annual onsite quality reviews for contractors who participate in the Contract for Fee Program.

We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service uses a standard template that includes terms and conditions that are consistent with those in the Readjustment Counseling Service policy.

We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Readjustment Counseling Service maintains and monitors counseling service contracts in accordance with Readjustment Counseling Service and Veterans Health Administration policy.

We recommended that the Under Secretary for Health, in conjunction with the Readjustment Counseling Service Chief Officer, ensure that Team Leaders authorize contracted counseling services in accordance with Readjustment Counseling Service and Veterans Health Administration policy.

We recommended that the Under Secretary for Health implement procedures to ensure that future VHA internal assessments resulting from adverse events include clear guidance to facilities on minimal required steps and supporting documentation.

We recommended that the Under Secretary for Health require facilities to develop processes for assessing the risks and benefits of adopting new medical products or devices that may require significant changes in nursing procedures.

We recommended that the Under Secretary for Health ensure that facility nursing education departments are sufficiently staffed to provide comprehensive and ongoing nursing education, especially when adopting new medical products or devices that may significantly change nursing procedures.

We recommended that the Under Secretary for Health address the reported compliance issues when revising the current Prevention of Legionella Disease directive.

We recommended that the Under Secretary for Health provide a plan that simplifies implementation of the directive, and that provides guidance, education, and monitoring of the implementation of the revised Prevention of Legionella Disease directive when issued.

We recommended that the Under Secretary for Health consider re-evaluation of the current stratification plan that identifies risk of Legionnaires’ disease based on transplant status.

We recommended that the Under Secretary for Health institute a national-level water safety committee that will provide expert and technical assistance for collaborative decision-making at the local level in the control and prevention of waterborne disease.

We recommend the Executive in Charge for the Office of Management and Chief Financial Officer coordinate with the Acting Assistant Secretary of the Office of Human Resources and Administration to implement existing telework expansion plans for reducing greenhouse gas emissions and to encourage VA employees to use alternative forms of commuting.

We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce greenhouse gas emissions.

We recommend the Executive in Charge for the Office of Management and Chief Financial Officer identify additional strategies for meeting requirements to reduce fleet petroleum consumption.

We recommend the Acting Assistant Secretary for Human Resources and Administration improve the development and management of ADVANCE-funded acquisitions by strengthening the Strategic Management Group's process to fully assess program offices' procurement requests against VA's existing internal capacities.

We recommend the Acting Assistant Secretary for Human Resources and Administration take immediate action to assess veteran demand for call center services and modify the terms of its interagency agreement with the Office of Personnel Management to reflect anappropriate level of call center operations and related costs, including staffing resources.

We recommend the Acting Assistant Secretary for Human Resources and Administration modify the Veteran Employment Services Office's interagency agreement with the Office of Personnel Management to require routine data reports on call centers' performance that include call volume, length of calls, blocked calls, wait times, and the overall accuracy of information provided to callers.

We recommend the Acting Assistant Secretary for Human Resources and Administration develop a process to independently assess the performance of the Veteran Employment Services Office's employment call centers by establishing metrics such as call volume, call wait times, hang-ups, and accuracy of information.

We recommend the Acting Assistant Secretary for Human Resources and Administration develop policy that prohibits the approval of modifications to interagency agreement terms that combine the costs and terms of distinct deliverables into one deliverable.

We recommend the Acting Assistant Secretary for Human Resources and Administration develop requirements to test and assess functions to be contracted to determine if these functions are inherently governmental as part of the acquisition planning process for all future contracts awarded to support the Veteran Employment Services Office's operations and initiatives.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians communicate positive CRC screening test, diagnostic test, and biopsy results to patients within 14 days and document notification in the EHR.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians document follow-up plans or document that no follow-up is warranted within 14 days of positive CRC screening results.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians discuss diagnostic testing options with patients and that desired testing is performed within 60 days of the positive CRC screening results.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians complete general or surgical evaluations within 30 days of positive CRC pathology.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently document all required elements of comprehensive pre-sedation assessments and that facilities monitor compliance.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that when there is a provider change, clinicians consistently document that the patient was informed of and agreed to the change and that facilities monitor compliance.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that clinicians consistently discharge MS patients appropriately and safely and that facilities monitor compliance.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that all facilities fully implement the staffing methodology and complete all required steps.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that facilities improve processes to use the available data to manage and provide safe, cost-effective staffing.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that facilities take action to improve post-discharge follow-up for MH patients, particularly those who were identified as high risk for suicide.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility leaders, ensures that clinicians consistently follow the required processes for patients who fail to report for scheduled MH appointments and document actions taken.

We recommended that the Under Secretary for Health, in conjunction with VISN senior managers, ensures that facility directors and Patient Safety Officers sit on the high-level committees that review QM results.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that completed corrective actions related to protected peer review are reported to the PRC.

We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers, ensures that FPPEs for newly hired licensed independent practitioners are initiated and completed and that results are reported to the MEC.

We recommend the Under Secretary for Benefits continue to issue certificates of eligibility until either 99,000 veterans have enrolled in an approved training program or until October 1, 2013, whichever occurs first.

We recommend the Under Secretary for Benefits revise the Veterans Retraining Assistance Program certificate of eligibility letter to inform veterans that Veterans Benefits Administration will only pay benefits to a limited number of veterans.

We recommend the Under Secretary for Benefits contact the veterans currently holding a certificate of eligibility, who have not yet enrolled in the approved training, and inform them that VBA will pay benefits only to a limited number of veterans. Inform the veterans they will need to check the VRAP Web site or contact VBA to confirm benefits are still available before enrolling in an approved training program.

We recommend the Under Secretary for Benefits provide retroactive benefits to VRAP participants (not to exceed the FY 2012 authorization) who were enrolled in an approved training program in FY 2012, but did not receive benefits before October 1, 2012.

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, monitor and ensure consistent verification and documentation of preoperative intraocular lens implant verification in the electronic health record for all cataract surgeries.

We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure the analysis of OSOD data and dissemination of associated quality improvement processes to VA cataract surgery facilities.

To ensure the integrity of the Merit Review process and the appropriateness of funding Dr. Y's research, we recommend that ORD conduct an Administrative Board of Investigation into Dr. X's actions and their consequent effects on the outcome of the review process, and to take appropriate actions, as indicated.

We recommend that ORD consider making modifications to the review process such as: (a) prohibiting SRG members from attending meetings where a spouse's (or immediate family member's) proposal is scheduled for discussion; (b) not posting reviewers' identities prior to the formal SRG group discussion; (c) blinding proposals so that reviewers cannot easily identify the author; and (d) requesting SRG members specify the proposals they are competent to review, but not asking for preferences or selection of primary, secondary, or tertiary reviewer roles.

We recommended the Under Secretary for Health implement its corrective action plan, as described in the Performance and Accountability Report, for reducing improper payments in the Non-VA Care Fee program.

We recommended the Under Secretary for Health develop achievable reduction targets for the Non-VA Care Fee program.

We recommended the Under Secretary for Health implement an improper payments estimation methodology that will achieve the required statistical precision for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.

We recommended the Under Secretary for Benefits develop and implement a statistically valid estimation methodology for the Compensation, Pension, and Vocational Rehabilitation and Employment programs for reporting on performance in meeting requirements of the Improper Payments Elimination and Recovery Act.

We recommended the Under Secretary for Benefits develop a process to collect and report the required improper payments recapture information.

We recommended the Executive in Charge for the Office of Management and Chief Financial Officer complete planned activities to improve compliance with the Improper Payments Elimination and Recovery Act and use this information to develop and issue additional guidance.

We recommended that the Under Secretary for Health ensure that VHA program officials provide additional guidance on what constitutes disruptive behavior and establish common terminology.

We recommended that the Under Secretary for Health ensure that VHA program officials develop guidelines for what information VHA facilities should document regarding disruptive incidents and where this information should be documented.

We recommended that the Under Secretary for Health ensure that VHA program officials provide guidance to VHA facilities on collecting and analyzing data on disruptive incidents.

We recommended that the Under Secretary for Health consider implementing a national reporting system or data collection template for disruptive patient incidents.

We recommended that the Under Secretary for Health ensure that VHA facilities implement procedures to ensure more timely assignment of Category I PRFs.

We recommend the Assistant Secretary for Information and Technology require that OIT personnel complete specialized training emphasizing the importance of encrypting sensitive VA data transmitted across public Internet connections.

We recommended that the Under Secretary for Health implement a plan to ensure compliance with VHA's requirement that patients who are at moderate or high risk for amputation be examined by a foot care specialist at least once each year.