Recommendations
638
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00388-266 | Inspection of Select Vet Centers in Pacific District 5 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Kauai Vet Center Director determine reasons for noncompliance with assigning a licensed mental health professional as a clinical liaison, ensure a process is implemented, and monitor compliance.
Closure Date:
2 District leaders and the Corona, Temecula, Kauai, and Western Oahu Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
3 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Corona, Temecula, Kauai, and Western Oahu Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with completion of a current written outreach plan, ensure completion, and monitor compliance.
Closure Date:
6 The District Director and zone leaders, in conjunction with the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and Western Oahu Vet Center Director determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.
8 District leaders and the Corona, Temecula, and Western Oahu Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
9 District leaders and the Temecula and Western Oahu Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Temecula Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
11 District leaders and the Corona, Temecula, and Kauai Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
12 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
13 District leaders and the Kauai and Western Oahu Vet Center Directors determine reasons for noncompliance with having an updated emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
14 District leaders and the Western Oahu Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 24-00389-267 | Inspection of Select Vet Centers in Pacific District 5 Zone 3 | Vet Center Inspection Program | ||
1 District leaders and the Phoenix and West Valley Vet Center Director collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
Closure Date:
2 District leaders and the Antelope Valley, Phoenix, and West Valley Vet Center Directors determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
Closure Date:
3 District leaders and the West Valley Vet Center Director determine reasons for noncompliance with Vet Center Director review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
4 District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Antelope Valley, Phoenix, Santa Fe, and West Valley Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Antelope Valley Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
8 District leaders and the Antelope Valley and Santa Fe Vet Center Directors determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
Closure Date:
9 District leaders and the Phoenix and Santa Fe Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Santa Fe Vet Center Director determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
Closure Date:
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| 23-03679-262 | Leaders Failed to Address Community Care Consult Delays Despite Staff’s Advocacy Efforts at VA Western New York Healthcare System in Buffalo | Hotline Healthcare Inspection | ||
1 The New York/New Jersey VA Health Care Network Director conducts a review of system leaders’ responses to repeated concerns regarding delayed community care consult scheduling for patients with serious health conditions to determine whether leaders’ actions were in alignment with patient safety and high reliability organizational principles, and take action as warranted.
Closure Date:
2 The New York/New Jersey VA Health Care Network Director ensures VA Western New York Health Care System Director develops community care consult practices and procedures for managing consults deemed high-risk or complex, implements an effective process to ensure consistency with processing consults within Veterans Health Administration timeliness requirements, and audits for compliance.
Closure Date:
3 The VA Western New York Health Care System Director ensures system community care leaders develop and implement standardized operating procedures for consult management consistent with Veterans Health Administration standards, provide training to community care staff, monitor compliance, and evaluate effectiveness.
Closure Date:
4 The VA Western New York Health Care System Director ensures all efforts to conduct an institutional disclosure to Patient A’s family are made and that the disclosure is documented in the patient’s electronic health record, as required.
Closure Date:
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| 23-02393-250 | Mismanaged Mental Health Care for a Patient Who Died by Suicide and Review of Administrative Actions at the VA Tuscaloosa Healthcare System in Alabama | Hotline Healthcare Inspection | ||
1 The VA Tuscaloosa Healthcare System Director conducts a full review of care provided to the patient by clinical staff, consults with Human Resources and General Counsel Offices, and takes action as needed.
Closure Date:
2 The VA Tuscaloosa Healthcare System Director strengthens processes to ensure that providers provide patient education about applicable boxed warnings when prescribing psychiatric medication, and monitors compliance.
3 The VA Tuscaloosa Healthcare System Director ensures mental health staff conduct suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.
4 The VA Tuscaloosa Healthcare System Director evaluates outpatient mental health clinic scheduling procedures; identifies barriers to timely appointment scheduling, including staffing levels; and takes action as warranted.
Closure Date:
5 The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adequate lethal means assessment and lethal means safety counseling with patients.
6 The VA Tuscaloosa Healthcare System Director reviews posttraumatic stress disorder clinic processes to consult with a patient’s prescriber following worsening of a patient’s mental health symptoms.
Closure Date:
7 The VA Tuscaloosa Healthcare System Director ensures posttraumatic stress disorder clinic consult and documentation procedures align with Veterans Health Administration requirements.
Closure Date:
8 The VA Tuscaloosa Healthcare System Director conducts a review of the supervisory oversight of the social worker and other clinicians in the posttraumatic stress disorder clinic to ensure the identification and follow-up of clinical concerns for patients with complex mental health needs.
9 The VA Tuscaloosa Healthcare System Director strengthens processes to ensure adherence to Veterans Health Administration and facility traumatic brain injury screening and consult requirements, and monitors compliance.
Closure Date:
10 The VA Tuscaloosa Healthcare System Director evaluates the root cause analysis processes regarding reporting of incomplete action items in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.
Closure Date:
11 The VA Tuscaloosa Healthcare System Director evaluates the Peer Review Committee processes on addressing identified system issues in accordance with Veterans Health Administration requirements, takes action as needed, and monitors compliance.
Closure Date:
12 The Under Secretary for Health considers establishing written guidance regarding the Behavioral Health Autopsy Program family interview process, including suicide prevention program staff’s consultation, to ensure that the decision to not outreach a family member is based on the best interest of the family.
Closure Date:
13 The VA Tuscaloosa Healthcare System Director ensures compliance with the Behavioral Health Autopsy Program including completion of the Family Interview Tool-Contact Form.
Closure Date:
14 The VA Tuscaloosa Healthcare System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
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| 24-00675-259 | Mental Health Inspection of the VA Augusta Health Care System in Georgia | Mental Health Inspection Program | ||
1 The VA Augusta Health Care System Director ensures that the Mental Health Executive Council includes veteran representation.
Closure Date:
2 The Veterans Integrated Service Network Director implements processes to strengthen oversight and monitoring of bed utilization.
Closure Date:
3 The VA Augusta Health Care System Associate Director for Patient Care Services ensures that inpatient mental health unit staffing supports authorized bed capacity.
Closure Date:
4 The VA Augusta Health Care System Director develops and implements processes to incorporate veteran input for process improvements.
5 The VA Augusta Health Care System Chief of Mental Health develops processes to ensure integration of the Local Recovery Coordinator into the inpatient mental health unit to support recovery-oriented care.
Closure Date:
6 The VA Augusta Health Care System Chief of Mental Health ensures a minimum of four hours of recovery-oriented, interdisciplinary programming on weekends on the inpatient mental health unit.
7 The VA Augusta Health Care System Director ensures continued implementation of a recovery-oriented environment on the inpatient mental health unit.
Closure Date:
8 The VA Augusta Health Care System Director ensures accurate reporting of inpatient operating beds and implements processes to monitor.
Closure Date:
9 The VA Augusta Health Care System Director identifies and addresses barriers to admission for veterans on involuntary holds for mental health treatment.
Closure Date:
10 The VA Augusta Health Care System Director ensures alignment between involuntary commitment policies and practices, consistency with state laws, and implementation of monitoring processes.
11 The VA Augusta Health Care System Chief of Staff ensures assignment of ongoing responsibilities for monitoring timely documentation of the change in veterans’ voluntary or involuntary legal status, consistent with VHA policy and state laws.
Closure Date:
12 The VA Augusta Health Care System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for improvement.
Closure Date:
13 The VA Augusta Health Care System Director ensures the development and implementation of clearly defined written processes for transition of care when veterans are discharged from the inpatient mental health unit.
Closure Date:
14 The VA Augusta Health Care System Chief of Staff ensures discharge summaries are completed within two business days of discharge and monitors for compliance.
Closure Date:
15 The VA Augusta Health Care System Chief of Staff ensures discharge instructions for veterans include appointment location and contact information in easy-to-understand language.
Closure Date:
16 The VA Augusta Health Care System Director ensures that medications listed in discharge instructions include the purpose for each medication and are written in easy-to-understand language.
17 The VA Augusta Health Care System Chief of Staff identifies barriers to completing the Columbia-Suicide Severity Risk Scale Screener within 24 hours prior to discharge, implements processes, and monitors to ensure compliance.
Closure Date:
18 The VA Augusta Health Care System Chief of Staff ensures that safety plans address ways to make the veteran’s environment safer from potentially lethal means and monitors for compliance.
Closure Date:
19 The VA Augusta Health Care System Director ensures staff comply with lethal means safety training and suicide risk training requirements and monitors for compliance.
20 The VA Augusta Health Care System Director ensures compliance with VHA requirements for the Interdisciplinary Safety Inspection Team, including environment of care subcommittee structure, and Mental Health Environment of Care Checklist training completion.
Closure Date:
21 The VA Augusta Health Care System Chief of Staff ensures mental health leaders update inpatient unit toilets to meet safety requirements and implement processes to reduce associated safety risks.
Closure Date:
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| 23-02994-224 | Cardiothoracic Services Contracting at the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois, Needs Improvement | Review | ||
1 Ensure the Network Contracting Office 12 contracting officer develops a cardiothoracic services contract solution that meets the Medical Sharing/Affiliate National Program Office threshold for review.
Closure Date:
2 Establish procedures to regularly identify and review healthcare resources contracts that have been modified resulting in contract values that exceed the threshold and determine if any further action by Regional Procurement Office Central leaders or the head of contracting activity is necessary.
Closure Date:
3 Ensure the Network Contracting Office 12 contracting officer makes the sole-source contract justifications publicly available as required.
Closure Date:
4 Ensure corrective actions are taken to resolve the issues identified in the Medical Sharing/Affiliate National Program Office fact-finding investigation.
Closure Date:
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| 23-01624-243 | VHA Needs to Establish Controls for Its Ambulatory Care Budget Estimate | Audit | ||
1 Establish and implement guidance for quality assurance measures over the data used to develop and justify the ambulatory care budget estimate.
2 Ensure the deputy under secretary for health provides oversight and holds the Office of Finance accountable for developing, documenting, and implementing standard operating procedures to include defining roles and responsibilities and requirements for oversight and quality assurance for development of the ambulatory care budget estimate.
3 Implement the Veterans Health Administration Data Governance Council, to include developing policies and processes for data management across the Veterans Health Administration.
4 Ensure the Veterans Health Administration Data Governance Council identifies authoritative data sources and nominates data stewards for approval by the VA Data Governance Council.
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| 23-03128-213 | Alleged Mismanagement of Contracts for Wheelchair-Accessible Transportation Services by the Health Administration Service at the Dallas VAMC in Texas | Review | ||
1 Coordinate with the Health Administration Service chief to develop local policy and standard operating procedures to ensure wheelchair-accessible transportation service invoices are adequately reviewed before certification for payment in accordance with financial policy and contract documentation.
Closure Date:
2 Recover approximately $3.7 million from the contractor for transportation overcharges.
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| 24-00601-254 | Healthcare Facility Inspection of the VA Hudson Valley Healthcare System in Montrose, New York | Healthcare Facility Inspection | ||
1 The OIG recommends that facility leaders submit a plan to the OIG detailing steps to address snow removal on pathways leading to and from buses during and after snowstorms.
Closure Date:
2 The OIG recommends that facility leaders consider clarifying signage by identifying the services located in each building to help direct veterans.
Closure Date:
3 The OIG recommends that facility leaders implement navigation tools and cues that accommodate visually impaired veterans to help them enter the main doors.
Closure Date:
4 The OIG recommends that facility leaders consider distributing toxic exposure screening information where veterans can easily obtain it when entering the facility.
Closure Date:
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| 24-00585-246 | Healthcare Facility Inspection of the VA Orlando Healthcare System in Florida | Healthcare Facility Inspection | ||
1 The OIG recommended the Facility Director work with Veterans Integrated Service Network leaders to reevaluate the current bed level capacity and submit the bed change request as required.
Closure Date:
2 The OIG recommended the Facility Director ensures staff secure the pneumatic tube system to prevent unauthorized access to medications.
Closure Date:
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11259