Date Issued
|
Report Number
14-02890-255
All Reports
Date Issued
|
Report Number
15-00650-423
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
We recommended the Veterans Integrated Service Network 12 Acting Director ensure management at the William S. Middleton Veterans Hospital complies with the facility policy requiring all equipment requests contain sufficient and accurate information to justify the acquisition request.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/26/2017
We recommended the Veterans Integrated Service Network 12 Acting Director ensure all laser lead extractors within the Veterans Integrated Service Network are being utilized to the extent possible.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 409,771.00
Date Issued
|
Report Number
15-00084-370
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/26/2019
We recommended that the Facility Director ensure that recommendations, if any, from other reviews of the surgical program be implemented.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/2/2017
We recommended that the Facility Director implement procedures to ensure patients are adequately evaluated by medicine and anesthesia providers prior to surgery.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the Facility Director ensure that peer reviews are conducted as required when criteria are met.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/7/2017
We recommended that the Facility Director implement processes to ensure that necessary surgical supplies, equipment, and instruments are available, functional, and duplicated as needed.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/29/2017
We recommended that the Facility Director evaluate the organizational structure for parity concerning surgical technician positions.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 8/2/2017
We recommended that the Facility Director ensure that the surgical post-operative clinic uses the same nurse staffing methodology as other outpatient clinics.
Date Issued
|
Report Number
14-05118-147
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 4/19/2017
We recommended the Acting Under Secretary for Benefits improve outreach by periodically requiring Education Liaison Representatives to review Post-9/11 G.I. Bill and Yellow Ribbon Program requirements, the School Certifying Official Handbook, and other available Veterans Benefits Administration training resources with School Certifying Officials to help them submit accurate and complete tuition and fee certifications.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits develop risk profiles for schools that are prone to certification problems, improper payments, and missed recoupments; and implement a process to periodically review and verify the certification information submitted by these schools.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits incorporate improper payment and missed recoupment risk factors into Veterans Benefits Administration’s risk-based system for the prioritization and completion of compliance surveys.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 5/23/2017
We recommended the Acting Under Secretary for Benefits revise the School Certifying Official Handbook to clarify guidance on allowable book and supply fees.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 10/25/2017
We recommended the Acting Under Secretary for Benefits review and strengthen Education Service policies and controls regarding the discontinuance and recoupment of payments, repeated classes, and satisfactory academic progress to ensure compliance with Federal regulations and prevent possible education benefits abuse.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/21/2017
We recommended the Acting Under Secretary for Benefits ensure that mitigating circumstances are properly verified and supporting documentation is obtained before tuition repayments are forgiven.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 1/9/2018
We recommended the Acting Under Secretary for Benefits initiate action to recover identified improper payments when collections are deemed appropriate and reasonable.
No. 8
to Veterans Benefits Administration (VBA)
Closure Date: 9/30/2016
We recommended the Acting Under Secretary for Benefits review the identified missed recoupments to determine if collections would be appropriate and reasonable.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,270,000,128.00
Date Issued
|
Report Number
14-00875-325
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/30/2016
We recommended that the System Director ensure that primary care providers are notified of specialty evaluations and treatment plans so they can be involved in care coordination.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the System Director ensure that staff assesses patient learning needs, barriers, abilities and readiness to learn, and that related education is provided as required by local policy, and monitor for compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/26/2017
We recommended that the System Director ensure that all patients are annually screened for depression, or more frequently as indicated by existing or newly identified risks, and that system manager’s monitor for compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 8/10/2017
We recommended that the System Director ensure that documentation from non-VA clinical care, including radiology reports, are obtained and available in the electronic health record for review in a timely and consistent manner.
No. 5
to Veterans Health Administration (VHA)
We recommended that the System Director ensure that system staff place consults with urgency based on the needed response time.
No. 6
to Veterans Health Administration (VHA)
We recommended that the System Director review facility service agreements and care coordination in order to better care for patients with complex diseases that require multi-specialty intervention.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/26/2017
We recommended that the System Director review this case and consult with the Office of Chief Counsel (formerly Regional Counsel) regarding the care provided and take action if appropriate.
Date Issued
|
Report Number
15-01982-113
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that primary care providers are able to assess, treat, monitor, and reassess patients on chronic opioid therapy within the appropriate timeframe.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that the Veterans¿ Integrated Pain Management Clinic meets non-opioid pain management needs of patients as evidenced by timely consultation completions.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director consider the clinical and administrative demands of chronic opioid therapy care when determining appropriateness of primary care provider staffing and that staffing plans are in place for planned and unplanned provider vacancies and absences.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that benzodiazepine appropriateness evaluations are completed as required for chronic opioid therapy patients with post-traumatic stress disorder.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure that primary care and mental health providers communicate and coordinate care for post-traumatic stress disorder patients receiving both opioids and benzodiazepines.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 9/29/2016
We recommended that the Facility Director ensure regular communication between facility leadership and community based outpatient clinic leadership to support consistent high quality care.
Date Issued
|
Report Number
14-04274-418
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director charter a team to evaluate the facility's entire process involving reusable medical equipment in accordance with applicable guidelines, integrate reviews' recommendations, and develop an overarching reusable medical equipment management plan.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable national and local policies and guidelines for the reprocessing of reusable medical equipment and the preparation of trays and instrument lists.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/3/2017
We recommended that the System Director ensure that Sterile Processing Service staff comply with applicable guidelines to record daily temperature and humidity levels in Sterile Processing Service areas and act upon and document actions when temperature and humidity levels are out of range.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure that an ergonomic assessment be made of the physical access and weight of items stored in the operating room Sterile Processing Service storage area and ensure staff safety and compliance with applicable Occupational Safety and Health Administration standards.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure training of operating room staff in proper handling of sterile packages and establish a formal process to track and trend issues with packages.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure adequate staffing to manage the operational requirements of Sterile Processing Service.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director ensure that the operating room and Sterile Processing Service staff implement a reusable medical equipment quality control program consistent with Veteran Health Administration guidelines.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 3/8/2017
We recommended that the System Director implement measures to improve collaboration and communication within and between operating room and Sterile Processing Service staff.
Date Issued
|
Report Number
15-02707-277
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 9/29/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to prevent staff from completing a decision without considering potential eligibility to statutory housebound benefits any time a veteran has a single 100 percent evaluation.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 2/27/2018
We recommended the then Acting Under Secretary for Benefits conduct a review of all veterans being paid compensation at the housebound rate with a combined evaluation of 90 percent or less and provide certification of completion of the review to the Office of Inspector General.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits establish a plan to conduct periodic reviews of high-risk cases in which housebound benefits are being paid.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 4/5/2017
We recommended the then Acting Under Secretary for Benefits implement a plan to provide all decision-makers the updated special monthly compensation training and monitor the effectiveness of the training.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits establish a plan to update the electronic system to ensure staff discontinue temporary housebound benefits when the criteria are no longer met.
No. 6
to Veterans Benefits Administration (VBA)
Closure Date: 2/15/2017
We recommended the then Acting Under Secretary for Benefits remind staff of the requirements to use the Special Monthly Compensation Calculator in all special monthly compensation cases and include the results in the file, and implement a plan to ensure compliance.
No. 7
to Veterans Benefits Administration (VBA)
Closure Date: 12/9/2016
We recommended the then Acting Under Secretary for Benefits clarify the meaning of the term substantially confined for housebound in-fact benefits.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 154,400,000.00
Date Issued
|
Report Number
16-00351-453
|
Topics: Staffing
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health ensure that the Veterans Health Administration develops staffing models for critical need occupations, and we further recommend that the Veterans Health Administration sets forth milestones and a timetable for further critical need occupations’ staffing model development, piloting, and implementation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We restated our previous recommendation that the Under Secretary for Health review data on regrettable losses and consider implementing measures to reduce such losses.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health consider incorporating data that predicts changes in veteran demand for health care into its staffing model.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/4/2018
We recommended that the Under Secretary for Health assess the Veterans Health Administration’s resources and expertise in developing staffing models and determine whether exploration of external options to develop the above staffing model is necessary.
Date Issued
|
Report Number
15-00018-349
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/27/2016
We recommended that the Facility Director ensure that all patients who experienced delays in notifications of positive fecal immunochemical tests are assessed to determine if appropriate follow-up care was rendered and whether the delays adversely affected the patients¿ clinical outcomes.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/27/2016
We recommended that the Facility Director confer with the Office of Chief Counsel (formerly known as Regional Counsel) regarding the care of the four patients described in this report and any additional patients identified in further review who may have been adversely affected, to determine the appropriate action to take, if any.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that the Facility Director ensure that providers communicate positive colorectal cancer screening results to patients and document notifications in electronic health records according to Veterans Health Administration test notification policy.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/9/2017
We recommended that the Facility Director ensure that processes are in place to monitor providers’ compliance with Veterans Health Administration colorectal cancer screening policy.
Date Issued
|
Report Number
16-03960-428
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/8/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that employees consistently ask inpatients whether they want to discuss advance directives and that facility managers monitor compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/8/2017
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when inpatients request a discussion about advance directives, clinicians consistently document that the discussion occurred using only the two Veterans Health Administration standardized note titles for advance directive discussions and that facility managers monitor compliance.
Date Issued
|
Report Number
15-01396-525
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 6/12/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure sufficient oversight on all high-dollar value and complex acquisitions to prevent violations of acquisition regulations and VA policies.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 8/17/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) ensure critical planning actions—requirements development, market research, and independent government cost estimates are performed and provided to contracting officers, prior to developing requests for proposals.
No. 3
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 6/12/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) obtain pricing analysis and technical assistance, to ensure quality products and services are procured at fair and reasonable contract prices.
No. 4
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 6/12/2017
We recommended the Principal Executive Director for Acquisition, Logistics, and Construction (and Chief Acquisition Officer) enforce compliance with the VA policy to document all required acquisition decisions in the Electronic Contract Management System.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 16,800,000.00
Date Issued
|
Report Number
15-05328-373
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Facility Director ensure that the selection of a colorectalcancer screening method is based on a shared decision-making process between apatient and his/her provider and that the patient‘s preference is honored.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/22/2016
We recommended that the Facility Director define and communicate current localprocesses for obtaining screening colonoscopies.
Date Issued
|
Report Number
15-04655-347
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/17/2017
We recommended that the VA Pacific Islands Health Care System Director continue efforts to enhance the availability of, and access to, a comprehensive network of care and services.
Date Issued
|
Report Number
15-03706-330
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 2/15/2017
We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction ensure required reconciliations of cost estimates be performed prior to releasing construction design documents for all major construction projects.
No. 2
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 7/31/2017
We recommended the Principal Executive Director of Office of Acquisition, Logistics, and Construction provide sufficient, adequately trained and experienced staff to ensure appropriate oversight is provided over all phases for future major construction projects.
No. 3
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/21/2016
We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction establish policies and procedures to ensure disputes are resolved before proceeding with projects when actual cost and schedule milestones exceed established planned thresholds.
No. 4
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 9/21/2016
We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction implement mechanisms to ensure that adequate acquisition plans for major construction projects are completed at each appropriate acquisition stage.
No. 5
to Acquisitions, Logistics, and Construction (OALC)
Closure Date: 7/31/2017
We recommended the Principal Executive Director of the Office of Acquisition, Logistics, and Construction ensure adequate controls are implemented and monitored to verify change requests are processed timely.
Date Issued
|
Report Number
15-03942-392
Date Issued
|
Report Number
15-02776-240
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/19/2016
We recommended the Deputy Assistant Secretary for Acquisition and Logistics implement a mechanism to ensure proper coordination between the Veterans Affairs Acquisition Academy and Office of Logistics and Supply Chain Management when developing logistics training.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 1,862,856.00
Date Issued
|
Report Number
16-00623-306
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology improve VA’s email security filtering software configuration controls to effectively flag improper transmissions of veterans’ personally identifiable information over the VA network.
No. 2
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology establish Memoranda of Understandings with third party organizations that define network responsibilities, processes and procedures for handling sensitive veterans’ information, and require information security controls are implemented commensurate with VA’s information security standards.
No. 3
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology evaluate whether permanent encryption controls are needed for non-VA employees who maintain VA accounts for conducting business on behalf of veterans.
No. 4
to Information and Technology (OIT)
Closure Date: 9/15/2016
We recommended the VA Assistant Secretary for Information and Technology conduct reviews of processes, procedures, and controls in place at VA regional offices that collaborate with third party organizations to ensure security of sensitive veterans’ information.
Date Issued
|
Report Number
15-03713-288
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/14/2016
We recommended that the Interim Facility Director strengthen processes to ensure suicide prevention training is completed per Veterans Health Administration Directive 1071 and monitor compliance.
Date Issued
|
Report Number
15-01994-238
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/7/2016
We recommended the VA Northwest Health Network management assign a local Contracting Officer¿s Representative and Information Security Officer to provide oversight of Alaska VA Healthcare System contractors.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 9/7/2016
We recommended the VA Northwest Health Network management, in conjunction with the Assistant Secretary for Information and Technology, ensure that ProCare personnel complete VA's information security awareness training and sign the Contractor Rules of Behavior.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/11/2017
We recommended the Assistant Secretary for Information and Technology conduct a site assessment of information security controls at the ProCare facility, to include a risk assessment to determine the extent that any sensitive veteran data may have been compromised and, if so, with appropriate corrective action, to ensure compliance with VA and Federal information security requirements.