Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-02601-07 | Combined Assessment Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
Closure Date:
2 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
Closure Date:
3 We recommended that the facility implement an effective fee basis referral process to ensure patients receive diagnostic testing within the required timeframe and that compliance with the new process be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
Closure Date:
5 We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
Closure Date:
6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
7 We recommended that the facility establish an EHR Committee that meets VHA requirements and clearly define the responsibilities of the committee.
Closure Date:
| ||||
| 12-02189-14 | Combined Assessment Program Review of the VA Long Beach Healthcare System, Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken.
Closure Date:
3 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
Closure Date:
4 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
Closure Date:
5 We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe.
Closure Date:
6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
7 We recommended that processes be strengthened to ensure that outpatients who need interdisciplinary care have treatment plans developed.
Closure Date:
8 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
Closure Date:
9 We recommended that all discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that discharge instructions address diet and the initial follow-up appointment.
Closure Date:
11 We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and documented.
Closure Date:
12 We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
Closure Date:
13 We recommended that processes be implemented to report results of tracking and trending of inter-facility transfers to the Organizational Excellence Board and to incorporate education on inter-facility transfers into new resident orientation.
Closure Date:
14 We recommended that processes be strengthened to ensure that EOC deficiencies are corrected within the required timeframe and that action plans are submitted for deficiencies not corrected within the required timeframe.
Closure Date:
15 We recommended that facility managers conduct a comprehensive EOC inspection of the facility and take appropriate actions to correct identified general cleanliness and maintenance issues.
Closure Date:
| ||||
| 12-02098-11 | Healthcare Inspection – Reusable Medical Equipment Issues, VA Northern California Health Care System, Sacramento, CA | Hotline Healthcare Inspection | ||
1 The VISN Director requires the System Director to review the findings in this report and take steps to correct all identified deficiencies.
Closure Date:
| ||||
| 12-01487-08 | Healthcare Inspection - Delay in Treatment, Louis Stokes VA Medical Center, Cleveland, OH | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director strengthen local policies by including all VHA required elements regarding procedures for contacting patients to schedule appointments.
Closure Date:
2 We recommended that the Facility Director strengthen processes for clinic scheduling and consult tracking and monitor timeliness of outpatient scheduling processes for adherence with Veterans Health Administration timeliness requirements.
Closure Date:
| ||||
| 12-01903-04 | Review of VA's Alleged Incomplete Installation of Encryption Software Licenses | Audit | ||
1 We recommended the Assistant Secretary for Information Technology complete the software encryption project assessment to determine whether to continue or terminate the project.
Closure Date:
2 We recommended the Assistant Secretary for Information Technology, if it is determined to continue the project, develop a plan that includes sufficient human resources and monitoring to install and activate all of the purchased encryption software licenses.
Closure Date:
| ||||
| 12-02599-03 | Combined Assessment Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that compliance be monitored.
Closure Date:
2 We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
3 We recommended that minimum polytrauma staffing levels be maintained.
Closure Date:
4 We recommended that the facility monitor compliance with polytrauma training requirements.
Closure Date:
5 We recommended that processes be strengthened to ensure that Case Managers consistently communicate with the inpatient and/or their family at the required intervals.
Closure Date:
6 We recommended that processes be strengthened to ensure that polytrauma patient care areas are clean and well maintained.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff document all required elements in response to critical values on a nursing progress note or the Nursing Critical Value Template note.
Closure Date:
8 We recommended that nursing managers monitor the staffing methodology that was implemented in May 2012.
Closure Date:
| ||||
| 10-04045-124 | Audit of VBA's Liquidation Appraisal Oversight in the Cleveland and Phoenix Regional Loan Centers | Audit | ||
1 We recommended the Under Secretary for Benefits revise Loan Guaranty Service policies and procedures to include more specific criteria for evaluating appraisal comparable property selections and sales price adjustments.
Closure Date:
2 We recommended the Under Secretary for Benefits implement an automated appraisal review system to evaluate every liquidation appraisal.
Closure Date:
3 We recommended the Under Secretary for Benefits fully implement all defined elements of the Loan Guaranty Service Risk Management Program.
Closure Date:
4 We recommended the Under Secretary for Benefits revise the performance plan of the appropriate Loan Guaranty Service manager to ensure accountability for accomplishment of specific Risk Management Program requirements.
Closure Date:
| ||||
| 12-00165-277 | Review of Alleged Delays in VA Contractor Background Investigations | Audit | ||
1 We recommend that the Assistant Secretary for Operations, Security, and Preparedness implement improved policies, procedures, and practices to reduce the backlog of contractor background investigations and educate appropriate personnel on VA's personnel security requirements and contractor on-boarding processes.
Closure Date:
2 We recommend that the Assistant Secretary for Operations, Security, and Preparedness, in conjunction with the Assistant Secretary for Information Technology, implement a central case management system to automate the background investigation process and effectively monitor VA contractor status and associated contract costs during the background investigation process.
Closure Date:
| ||||
| 12-02525-291 | Administrative Investigation of the FY 2011 Human Resources Conferences in Orlando, Florida | Administrative Investigation | ||
1 We recommended the VA Secretary take the appropriate action against Mr. Sepúlveda.
Closure Date:
2 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Muellerweiss and ensure that action is taken.
Closure Date:
3 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Deanes and ensure that action is taken.
Closure Date:
4 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Dr. McMahan and ensure that action is taken.
Closure Date:
5 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Barritt and ensure that action is taken.
Closure Date:
6 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Dudley and ensure that action is taken.
Closure Date:
7 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Thomas and ensure that action is taken.
Closure Date:
8 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Gingrich and ensure that action is taken.
Closure Date:
9 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Dr. McMahan and ensure that action is taken.
Closure Date:
10 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Coke and ensure that action is taken.
Closure Date:
11 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Pleso and ensure that action is taken.
Closure Date:
12 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. McIntosh-Moore and ensure that action is taken.
Closure Date:
13 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Wakeley and ensure that action is taken.
Closure Date:
14 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Dudley and ensure that action is taken.
Closure Date:
15 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Barritt and ensure that action is taken.
Closure Date:
16 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Ms. Caruso and ensure that action is taken.
Closure Date:
17 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Gardner and ensure that action is taken.
Closure Date:
18 We recommended the VA Secretary confer with Human Resources officials outside VA Central Office's Office of Human Resources Management and attorneys in the Office of General Counsel to determine the appropriate administrative action to take against Mr. Pierce and ensure that action is taken.
Closure Date:
19 We recommended the VA Secretary establish a policy that VA will no longer solicit lodging accommodation upgrades as part of contracts.
Closure Date:
20 We recommended the VA Secretary modify VA procedures to include a requirement for a detailed spend plan to ensure cost estimates are reasonable.
Closure Date:
21 We recommended the VA Secretary implement policy to ensure conference managers obtain subsequent authorization from the Chief of Staff or the Deputy Secretary once they determine estimated costs have been exceeded or other major changes occur.
Closure Date:
22 We recommended the VA Secretary require an after-action report be provided to the Chief of Staff or the Deputy Secretary identifying planned-versus-actual costs, including justifications for significant differences.
Closure Date:
23 We recommended the VA Secretary issue policy outlining requirements for authorizing, justifying, and conducting pre-planning site visits for conferences.
Closure Date:
24 We recommended the VA Secretary establish requirements to support major conferences with contracting officers and other support resources to ensure conferences and the supporting acquisitions are planned and managed in accordance with applicable regulations.
Closure Date:
25 We recommended the VA Secretary establish budgetary controls to ensure centralized accounting for individual conference expenditures.
Closure Date:
26 We recommended the VA Secretary ensure conference budgets are authorized and monitored to ensure appropriate expenditures.
Closure Date:
27 We recommended the VA Secretary establish controls to ensure senior officials exercise their responsibility and accountability for prudent management of conference funds.
Closure Date:
28 We recommended the VA Secretary require travelers and approvers to comply with the requirement to not incur hotel taxes in states which offer tax exemption to the Government.
Closure Date:
29 We recommended the VA Secretary require conference planning committees to identify, by name, individuals needed onsite for conference support before or after the conference and that this designation be provided to the traveler for inclusion in their travel receipts.
Closure Date:
30 We recommended the VA Secretary require travelers and approving officials to comply with the requirement to include a cost comparison when choosing to use a privately owned vehicle instead of a government contracted mode of transportation.
Closure Date:
31 We recommended the VA Secretary develop a process to track and monitor the use of interagency agreements.
Closure Date:
32 We recommended the VA Secretary establish a mechanism to modify existing high-risk interagency agreements and ensure that all future interagency agreements account for costs associated with each single conference event.
Closure Date:
33 We recommended the VA Secretary establish a process to obtain detailed vendor invoice information to support tracking and validation of costs associated with interagency agreements.
Closure Date:
34 We recommended the VA Secretary require that all VA program offices (Administrations, Boards, Centers, and Offices) that plan meetings, conferences, or events involving more than 50 staff identify and clearly state all event requirements to minimize contract modifications.
Closure Date:
35 We recommended the VA Secretary develop a mechanism to ensure that commitments, expenditures, and combined liabilities exceeding $25,000 receive a legal and technical review.
Closure Date:
36 We recommended the VA Secretary ensure a Price Negotiation Memorandum be used to document negotiated agreements to minimize the possibility of future claims against the Government and to obtain a clear understanding from the contractor that all costs have been fully considered.
Closure Date:
37 We recommended the VA Secretary ensure contracting officers designate and authorize in writing a Contracting Officer's Representative on all contracts and orders other than those that are firm-fixed-price and for firm-fixed-price contracts as appropriate.
Closure Date:
38 We recommended the VA Secretary ensure that only authorized contracting personnel make commitments or changes that affect price, quality, quantity, delivery, or other terms and conditions of a contract.
Closure Date:
39 We recommended the VA Secretary ensure contract modifications are completed timely.
Closure Date:
40 We recommended the VA Secretary establish oversight mechanisms to eliminate excessive and wasteful conference expenditures of public funds.
Closure Date:
41 We recommended the VA Secretary ensure contracting officers document the results of all contract actions in VA's Electronic Contract Management System.
Closure Date:
42 We recommended the VA Secretary take action to ratify any legal agreements made by VA employees where there was no previous authority to commit payments for goods and/or services with the Marriott.
Closure Date:
43 We recommended the VA Secretary establish an effective cost system for credit card purchases that appropriately assigns costs to individual major VA events.
Closure Date:
44 We recommended the VA Secretary ensure purchase card approvers are trained on proper oversight of purchase card transactions.
Closure Date:
45 We recommended the VA Secretary ensure VA Learning University personnel with acquisition support responsibilities have valid warrants and that the warrants match their purchase authorization.
Closure Date:
46 We recommended the VA Secretary issue guidance regarding the proper procedures for transferring warrants within VA organizations.
Closure Date:
47 We recommended the VA Secretary ensure VA Learning University employees are trained on purchase card policies related to splitting purchases.
Closure Date:
48 We recommended the VA Secretary ensure supervisors have the required documentation prior to approving purchase card transactions.
Closure Date:
49 We recommended the VA Secretary require the Department to accomplish a special review of purchase card transactions made in support of VA Learning University conferences.
Closure Date:
| ||||
| 12-00375-290 | Review of the Enhanced Use Lease between the Department of Veterans Affairs and Veterans Development, LLC | Audit | ||
1 We recommend that the Under Secretary for Health develop a long range plan that addresses the significant space shortages at Wade Park caused by the EUL for the Brecksville division.
Closure Date:
2 We recommend that the Under Secretary for Health in coordination with the VAMC Cleveland Director, ensure the VAMC employees comply with the Privacy Act and other confidentiality statutes such as HIPAA and 38 U.S.C. § 7332, VHA Handbooks, and the Cleveland VAMC privacy policies, by appropriately safeguarding VA employees' PII and veterans' PHI.
Closure Date:
3 We recommend that the Under Secretary for Health in coordination with the VAMC Cleveland Director, ensure the VAMC employees receive training on records management and the provisions of applicable Records Management Retention schedules.
Closure Date:
4 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA’s General Counsel convene an independent group to determine the appropriateness and the legal sufficiency of the Brecksville EUL and service agreements contained in the EUL, particularly in light of the indictment of Michael Forlani and the suspension of VetDev and other entities identified in the indictment, and take appropriate action to include long and short term plans, including the renegotiation of the terms and conditions of the agreements for the administration building and the parking garage.
Closure Date:
5 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA’s General Counsel make a referral to the VA’s Procurement Executive for a determination whether any of the service agreements constitute an unauthorized commitment and, if so, take appropriate action to rectify the problem.
Closure Date:
6 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA’s General Counsel immediately determine what services VOA is actually performing and which services VA employees are performing and what services, if any, VA needs from VOA. Consideration should be given to simply leasing the existing space, with VA employees providing all the services, or relocating the domiciliary.
Closure Date:
7 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer and VA's General Counsel issue a bill of collection to VetDev to recoup the VA determined value of the overbilling relating to the failure to provide security services.
Closure Date:
8 We recommend that the Executive in Charge for the Office of Management and Chief Financial Officer take immediate steps to identify the security requirements for the administration building, parking, and domiciliary space and develop a plan of action to ensure the safety and security of VA employees, veterans, and their families.
Closure Date:
9 We recommend that the Under Secretary for Health, the Executive in Charge for the Office of Management and Chief Financial Officer, and VA's General Counsel do not execute any amendments to the current EUL or the service agreements to add additional space or services without review and approval by an independent third party. We recommend that any additional requirements for space by the Wade Park VAMC be reviewed and approved in advance by VHA's Chief Procurement Executive to ensure the legitimacy of the requirements, including the area of consideration.
Closure Date:
| ||||
14903