Recommendations
572
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-03672-199 | A Hiring Initiative to Expand Substance Use Disorder Treatment Needed Stronger Coordination, Planning, and Oversight | Review | ||
1 Instruct the Office of Finance to review the $14 million retained by the medical centers to ensure these funds were, or will be, spent in accordance with all applicable VA policies and federal laws.
Closure Date:
2 Require the Office of Finance to strengthen controls over designated specific purpose funds so that Veterans Integrated Service Network chief financial officers can account for all the distributed funds and make certain that the funds are used for the intended purpose.
Closure Date:
3 Define the roles and responsibilities of the appropriate assistant under secretaries, program office staff, and regional and medical center staff in the implementation and monitoring of the substance use disorder hiring initiative and ensure the relative priority of the initiative is communicated; hiring progress is monitored; possible hiring challenges are addressed to the extent possible; and actions are taken as needed to meet the goals of the hiring initiative.
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| 23-02907-216 | Follow-Up Financial Efficiency Inspection of the Southeast Louisiana Veterans Health Care System in New Orleans | Financial Inspection | ||
1 Establish internal controls to help ensure the healthcare system monitors the Medical/Surgical Prime Vendor product list for updates and completes the item conversion process
Closure Date:
2 Ensure that prime vendor contract performance issues are routinely reported to the Medical Supplies Program Office and the Strategic Acquisition Center using established Veterans Health Administration reporting tools.
Closure Date:
3 In coordination with the Strategic Acquisition Center, submit ratifications for any unauthorized commitments following the Federal Acquisition Regulation.
Closure Date:
4 Ensure that the facility-level contracting officer’s representative and ordering officers are appointed and delegated properly and perform all required duties according to the scope and limitation of the designee’s authority.
Closure Date:
5 Establish internal controls to help ensure the healthcare system submits national contract requests for waiver and justifications prior to purchasing available product list items from nonmandatory procurement instruments.
6 Ensure cardholders obtain a proper prior approval and maintain segregation of duties, and ensure that cardholders and approving officials perform prompt purchase card reconciliations as required by VA financial policy.
Closure Date:
7 Develop formalized processes and controls to ensure approving officials, cardholders, and the agency contracting office review repetitive open market purchases of goods and services and obtain contracts when it is determined to be in the best interest of the government.
Closure Date:
8 In coordination with the Strategic Acquisition Center, submit a ratification for an unauthorized commitment following the Federal Acquisition Regulation.
Closure Date:
9 Develop formalized processes for monitoring and achieving efficiency targets and using available pharmacy data to make business decisions.
10 Develop and implement a plan to increase inventory turnover to meet or exceed the VHA-recommended level, and complete monthly B09 reconciliations consistently to ensure discrepancies are corrected in a timely manner.
Closure Date:
11 Establish measures to improve compliance with the VA directive to avoid end-of-year pharmaceutical purchases.
Closure Date:
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| 23-01502-234 | Deficiencies in Facility Leaders’ Summary Suspension of a Provider and Patient Safety Reporting Concerns at the VA Black Hills Health Care System in Fort Meade, South Dakota | Hotline Healthcare Inspection | ||
1 The VA Black Hills Health Care System Director ensures that summary suspensions and related privileging actions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.
Closure Date:
2 The VA Black Hills Health Care System Director in conjunction with facility leaders and surgical service leaders, ensures a focused clinical care review is completed of the care provided by the subject provider according to Veterans Health Administration policy, and takes action as warranted.
Closure Date:
3 The VA Black Hills Health Care System Director, in conjunction with the National Center for Patient Safety, evaluates the patient safety event reporting processes, identifies deficiencies, and takes action as warranted to ensure compliance with entering adverse events or close calls into the Joint Patient Safety Reporting system.
Closure Date:
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| 23-03677-237 | Incorrect Use of the Baker Act at the North Florida/South Georgia Veterans Health System in Gainesville, Florida | Hotline Healthcare Inspection | ||
1 The VA North Florida/South Georgia Health System Director consults with the Office of General Counsel to ensure system and service line policies and practices related to voluntary and involuntary admissions under the Baker Act provide clear guidance and are consistent with Florida state law as allowed by federal law and Veterans Health Administration regulations.
Closure Date:
2 The VA North Florida/South Georgia Health System Director ensures that providers document their rationales for initiating involuntary examinations under the Baker Act within a patient’s electronic health record and monitors compliance.
3 The VA North Florida/South Georgia Health System Director verifies that a process is in place to provide patients who are admitted for an involuntary examination under the Baker Act with written information on their rights and monitors compliance.
Closure Date:
4 The VA North Florida/South Georgia Health System Director confirms that mental health staff document offering evidence-based therapies during treatment planning with patients diagnosed with posttraumatic stress disorder, as required by Veterans Health Administration policy, and monitors compliance.
Closure Date:
5 The VA North Florida/South Georgia Health System Director ensures that all licensed mental health staff receive annual training on the Baker Act and tracks compliance.
Closure Date:
6 The VA North Florida/South Georgia Health System Director determines if there is a need for non-mental health providers in the emergency department to complete Baker Act training and takes action as warranted.
Closure Date:
7 The VA North Florida/South Georgia Health System Director, in consultation with Veterans Health Administration’s Senior Security Officer, ensures system police, emergency department, and mental health staff follow VA policy specific to assisting staff in the prevention of patient elopements prior to an involuntary mental health evaluation and tracks compliance.
Closure Date:
8 The VA North Florida/South Georgia Health System Director develops a process to provide oversight of compliance with all elements required by state law for use of the Baker Act as permitted by federal law and Veterans Health Administration policy.
Closure Date:
9 The VA North Florida/South Georgia Health System Director, in consultation with the Office of General Counsel, determines whether Baker Act reporting by the system is required and provides clear guidance for applicable reporting processes.
Closure Date:
10 The VA North Florida/South Georgia Health System Director develops a process to ensure system policies adhere to Veterans Health Administration Directive 0999(1), medical center policy standardized template as it pertains to assignment of oversight responsibilities.
Closure Date:
11 The VA North Florida/South Georgia Health System Director directs a review of current patient advocate processes for follow-up and resolution with complainants, updates the process as warranted, and monitors compliance.
Closure Date:
12 The VA North Florida/South Georgia Health System Director considers having the patient advocate process for tracking and monitoring trends capture complaints specific to involuntary admissions for leaders’ awareness and follow-up.
Closure Date:
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| 23-01252-175 | VBA Needs to Improve Oversight of the Digital GI Bill Platform | Audit | ||
1 Establish a mechanism to monitor progress of the Digital GI Bill platform implementation under the renegotiated contract to avoid additional costs and delays.
Closure Date:
2 Communicate regularly with the Digital GI Bill platform contractor to ensure that the project’s integrated master schedule or other master scheduling plan is consistently updated to reflect all schedule changes for external dependencies.
Closure Date:
3 Develop strategies to address critical path failures to provide a clear timeline of further implementation activities.
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| 22-04108-235 | Inspection of Select Vet Centers in Continental District 4 Zone 2 | Vet Center Inspection Program | ||
1 District leaders and the Jackson and Corpus Christi Vet Center Directors 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 Fort Worth Vet Center Director determine reasons for noncompliance with Readjustment Counseling Service documentation standards, ensure completion, and monitor compliance.
3 District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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:
4 District leaders and the Jackson and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with Vet Center Directors review of 10 percent of active client records monthly for each counselor’s caseload, ensure completion, and monitor compliance.
Closure Date:
5 District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
Closure Date:
6 District leaders and the Fayetteville, New Orleans, Jackson, Corpus Christi, Fort Worth, and San Antonio Northeast 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 the Fayetteville 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:
8 District leaders and the New Orleans Vet Center Director determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
9 District leaders and the New Orleans, Jackson, and Corpus Christi Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Fayetteville and Fort Worth 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:
11 District leaders and the Fayetteville, Corpus Christi, Fort Worth, and San Antonio Northeast Vet Center Directors 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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| 22-04107-236 | Inspection of Select Vet Centers in Continental District 4 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne Vet Center Directors 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 Fort Collins, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Fort Collins, Abilene, and Salt Lake City Vet Centers Directors determine reasons for noncompliance with Vet Center Directors 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 Fort Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Fort Collins, Kalispell, Tulsa, Abilene, Salt Lake City, and Cheyenne 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 Cheyenne Vet Center Director determine reasons for noncompliance with completion of an annual fire or safety inspection, ensure completion, and monitor compliance.
Closure Date:
7 District leaders and the Abilene and Cheyenne 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.
Closure Date:
8 District leaders and the Fort Collins and Kalispell Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
Closure Date:
9 District leaders and the Salt Lake City Vet Center Director determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
Closure Date:
10 District leaders and the Fort Collins, Kalispell, Abilene, Salt Lake City, and Cheyenne Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
Closure Date:
11 District leaders and the Salt Lake City Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.
Closure Date:
12 District leaders and the Cheyenne Vet Center Director determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors, ensure completion, and monitor compliance.
Closure Date:
13 District leaders and the Fort Collins 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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| 22-04109-238 | Inspection of Continental District 4 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director monitors compliance with leaders’ completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.
Closure Date:
2 The District Director determines reasons vet center counselors did not complete safety plan components for clients assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures completion of safety plans for all active clients assesses at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.
Closure Date:
3 The District Director determines reasons staff did not document providing safety plans to clients, ensures that a safety plan was provided to all active clients assessed at intermediate or high suicide risk levels, and monitors compliance across all zone vet centers
Closure Date:
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| 23-00925-227 | Veterans Crisis Line Implementation of 988 Press 1 Preparation and Leaders' Response | National Healthcare Review | ||
1 The Veterans Crisis Line Director determines the optimal ratio of supervisors to frontline staff needed, makes the best efforts to ensure the ratio is maintained, and takes action as warranted.
Closure Date:
2 The Veterans Crisis Line Director ensures supervisors and staff are aware of postvention resources and monitors for compliance.
Closure Date:
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| 23-01965-217 | Incomplete Implementation of Corrective Actions to Address Pharmacy Service Concerns at the VA Central Western Massachusetts Healthcare System in Leeds | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures thorough completion of the VA Central Western Massachusetts Healthcare System pharmacy corrective actions, and takes action as needed.
Closure Date:
2 The Veterans Integrated Service Network Director ensures that pharmacy supervisors and staff at the VA Central Western Massachusetts Healthcare System receive the necessary training and written guidance to complete the corrective actions, and monitors for compliance.
Closure Date:
3 The Veterans Integrated Service Network Director ensures that leaders, whose actions contributed to the incomplete corrective actions and ineffective oversight, receive administrative action, as appropriate.
Closure Date:
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11259