Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 11-01406-247 | Healthcare Inspection Evaluation of Community Based Outpatient Clinics Fiscal Year 2011 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that each CBOC has a Women’s Health Liaison who collaborates with the parent facility’s Women Veterans Program Manager on women’s health issues.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that all breast imaging and mammography results are linked to the appropriate radiology mammogram or breast study order.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers Ensure that each medical center has a local policy for STFB consults.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers Ensure that practitioners document a justification for the use of STFB care in the medical record, specifically at urban CBOCs.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers Ensure there is documentation in the medical record that the patient received written notification STFB consult approval, specifically at urban CBOCs.
Closure Date:
6 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that each CBOC has a plan that defines how MH emergencies that require a higher level of care are addressed.
Closure Date:
7 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure patient care staff members at CBOCs have ongoing competency assessments validated for identified core competencies.
Closure Date:
8 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that auditory privacy is maintained during the check-in process.
Closure Date:
9 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers ensure that all PII is secured and protected.
Closure Date:
10 We recommended that the Under Secretary for Health, in conjunction with VISN and facility senior managers network space vulnerabilities in accordance with VA policy.
Closure Date:
11 We recommended that the Under Secretary for Health, in conjunction with the VISN and facility senior managers review the invoice validation process to consider creating a standardized billable roster report to improve oversight and accuracy of billable patient lists, thereby reducing man hours currently performing those duties and potential overpayments.
Closure Date:
12 We recommended that the Under Secretary for Health, in conjunction with the VISN and facility senior managers strengthen the oversight of the contract acquisition process to ensure that adequate planning occurs and that proper approvals are documented in the contract management system [eCMS] in accordance with VHA Directives.
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13 We recommended that the Under Secretary for Health, in conjunction with the VISN and facility senior managers ensure that MH services for contract CBOCs are addressed in a separate contract or within the primary care contract.
Closure Date:
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| 10-03166-75 | Audit of VA Regional Offices' Appeals Management Processes | Audit | ||
1 We recommended the Under Secretary for Benefits identify and request the staffing resources needed to meet Veterans Benefits Administration’s processing goals and conduct de novo reviews on all appeals.
Closure Date:
2 We recommended the Under Secretary for Benefits revise productivity standards for decision review officers assigned to appeal processing to limit credit to actions that progress the appeal such as Notices of Disagreement, issuance of Statements/Supplemental Statements of the Case, conducting requested hearings, and certification of appeals.
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3 We recommended the Under Secretary for Benefits implement criteria requiring appeals staff to initiate a review or development for Notices of Disagreement and certified appeals within 60 days of receipt.
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4 We recommended the Under Secretary for Benefits revise current policy to require de novo reviews on all appeals.
Closure Date:
5 We recommended the Under Secretary for Benefits develop and implement a plan to provide adequate oversight to ensure staff record Notices of Disagreement into the Veterans Appeals Control and Locator System.
Closure Date:
6 We recommended the Under Secretary for Benefits establish a mechanism to ensure VA Regional Offices¿ staff take appropriate action to complete the appeal and provide a decision on the 145 appeals that were not processed.
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| 11-04081-142 | Audit of VA’s Duty Station Assignments | Audit | ||
1 The Assistant Secretary for Human Resources and Administration develop training for human resources personnel responsible for coding duty stations in the automated system to ensure they understand how to designate employee duty stations as well as the implications of virtual assignments.
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2 The Assistant Secretary for Human Resources and Administration issue policy requiring that at least annually, managers are notified of their employees' duty station assignments and validate the assignments.
Closure Date:
3 The Assistant Secretary for Human Resources and Administration establish an oversight mechanism to ensure that at least annually, managers are notified of their employees¿ duty station assignments and validate the assignments.
Closure Date:
4 The Assistant Secretary for Human Resources and Administration establish a mechanism to notify all VA employees at least annually of the definition of duty station, as well as the implications of virtual assignments on locality pay.
Closure Date:
5 The Assistant Secretary for Human Resources and Administration establish a control mechanism to provide annual notification to supervisors regarding the requirement to submit a Request for Personnel Action, Standard Form 52, if an employee¿s duty station changes.
Closure Date:
6 The Assistant Secretary for Human Resources and Administration provide guidance to human resources personnel regarding processing corrective actions when employees have received inaccurate locality pay, which will help ensure that recoupment efforts are appropriate.
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7 The General Counsel take action to recoup overpayments as appropriate, in accordance with VA guidance.
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8 The Assistant Secretary for Information and Technology take action to recoup overpayments as appropriate, in accordance with VA guidance.
Closure Date:
9 The Executive Director for the Office of Acquisition, Logistics, and Construction take action to recoup overpayments as appropriate, in accordance with VA guidance.
Closure Date:
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| 11-00312-127 | Audit of VHA’s Prosthetics Supply Inventory Management | Audit | ||
1 We recommended the Under Secretary for Health require VA medical centers to conduct comprehensive physical inventories of stocked prosthetic supplies, adjust Prosthetics Inventory Package and Generic Inventory Package quantities on hand to match physical inventory quantities, and begin eliminating identified excess inventories and purchasing supplies to avoid identified shortages.
Closure Date:
2 We recommended the Under Secretary for Health collaborate with the VA Office of Information and Technology to develop a detailed plan of the steps needed to replace Prosthetics Inventory Package and Generic Inventory Package with a comprehensive modern inventory system, including milestones for deliverables and a methodology for tracking progress.
Closure Date:
3 We recommended the Under Secretary for Health establish a mechanism to ensure VA medical center prosthetic supply inventory managers receive the training required by the Veterans Health Administration's Inventory Management Handbook.
Closure Date:
4 We recommended the Under Secretary for Health collaborate with the Executive Director, Office of Acquisition, Logistics, and Construction, to develop a VA Acquisition Academy curriculum and certification program for prosthetic supply inventory managers that includes training on the inventory management practices and techniques discussed in this report.
Closure Date:
5 We recommended the Under Secretary for Health revise the Veterans Health Administration's Inventory Management Handbook to require at least one prosthetic supply inventory manager from each VA medical center to attend VA's Acquisition Academy's Supply Chain Management School and become Certified VA Supply Chain Managers.
Closure Date:
6 We recommended the Under Secretary for Health establish a mechanism to identify surgical device implants stored in VA medical center inventories, perform cost/benefit analyses of using consignment agreements to procure identified surgical device implants, and when determined to be cost effective, establish surgical device implant consignment agreements.
Closure Date:
7 We recommended the Under Secretary for Health discontinue using the metric of comparing prosthetic excess supply inventory and budgets and establish a mechanism to ensure VA medical centers submit the prosthetic inventory performance metrics required by the Veterans Health Administration's Inventory Management Handbook.
Closure Date:
8 We recommend the Under Secretary for Health include performance measurement information on VA medical centers' management of prosthetic supplies in the monthly compliance report and distribute the reports in accordance with Inventory Management Handbook requirements.
Closure Date:
9 We recommended the Under Secretary for Health establish policies and procedures requiring Veterans Integrated Service Network Prosthetic Representatives to conduct cyclical reviews at VA medical centers within their jurisdiction to evaluate prosthetic supply inventory management practices and provide a comprehensive written report detailing the evaluation results to the Prosthetic and Sensory Aids Service Central Office and Veterans Integrated Service Network and VA medical center directors.
Closure Date:
10 We recommended the Under Secretary for Health revise the Veterans Health Administration's Inventory Management Handbook to address inadequacies related to exempting Prosthetic and Sensory Aids Service; complying with maximum stock level requirements; establishing normal, reorder, and emergency stock levels; and recording supply receipt and usage in automated inventory systems timely.
Closure Date:
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| 11-00733-95 | Audit of VA’s Internal Controls Over the Use of Disability Benefits Questionnaires | Audit | ||
1 We recommend the Under Secretary for Benefits develop internal controls within the disability benefits questionnaire process that will reduce the risk of fraud, such as notifying veterans and physicians that submitted information is subject to verification.
2 We recommend the Under Secretary for Benefits develop front-end controls for the disability benefits questionnaire process to verify the identity and credentials of private physicians who submit completed disability benefits questionnaires, including those entered into the Fast Track Claims Processing System.
3 We recommend the Under Secretary for Benefits develop a plan to measure compliance with the guidance contained in Fast Letter 11-36 pertaining to tracking claims where a disability benefits questionnaire was received as medical evidence.
4 We recommend the Under Secretary for Benefits develop controls to electronically capture information contained on completed disability benefits questionnaires.
5 We recommend the Under Secretary for Benefits update the policy manual with information on the disability benefits questionnaire process, to include procedures for verifying information on completed disability benefits questionnaires and tracking and monitoring completed disability benefits questionnaires.
6 We recommend the Under Secretary for Benefits take steps to improve quality assurance reviews by focusing reviews on disability benefits questionnaires that pose an increased risk of fraud.
7 We recommend the Under Secretary for Benefits establish control mechanisms to ensure that potential cases of fraud identified during the quality assurance review process are immediately forwarded to the Office of Inspector General.
8 We recommend the Under Secretary for Health identify key components of disability benefits questionnaires that should be reviewed as part of the Disability Examination Management Office’s quality assurance review process.
9 We recommend the Under Secretary for Health modify the process used to select claims reviewed by the Disability Examination Management Office’s quality assurance staff.
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| 11-01295-232 | Combined Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that QM data is consistently analyzed and that corrective actions are evaluated for effectiveness.
Closure Date:
2 We recommended that the designated UM Ad-Hoc Committee reviews UM data and that the facility approves the case exemptions for Physician UM Advisor review.
Closure Date:
3 We recommended that PR data summaries include all required elements and that the PRC monitor closure of issues identified or referred for follow-up to other venues.
Closure Date:
4 We recommended that ongoing FPPE be completed within the defined 12-month period and that monitoring data be maintained in the physicians¿ profiles.
Closure Date:
5 We recommended that adequate competency data be maintained in all physicians' profiles.
Closure Date:
6 We recommended that processes be strengthened to ensure that all violent incidents involving patients are discussed at the DBC.
Closure Date:
7 We recommended that annual bloodborne pathogens training and N95 respirator fit testing be completed and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that all components of written AD notification are provided to patients and that notification is documented in the medical record.
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| 09-03850-99 | Audit of the Veterans Service Network | Audit | ||
1 We recommend the Assistant Secretary, Office of Information and Technology, update the Integrated Master Schedule to reflect project interdependencies and incorporate work breakdown structures of VA’s other Information Technology initiatives that will rely on Veterans Service Network resources.
2 We recommend the Assistant Secretary, Office of Information and Technology, update the capital planning, budgeting, and program management documents to clearly communicate the current disposition and future plans for the Benefits Delivery Network legacy system.
3 We recommend the Assistant Secretary, Office of Information and Technology, define the level of effort and apply the resources required to complete data migration for all entitlement programs and decommission the Benefits Delivery Network legacy system.
4 We recommend the Assistant Secretary, Office of Information and Technology, address longstanding accounting functionality defects to ensure that benefit payments are accurately recorded within the Veterans Service Network.
5 We recommend the Assistant Secretary, Office of Information and Technology, prioritize resources to put the Veterans Service Network on track toward meeting the established completion schedule and program goals within anticipated cost parameters.
6 We recommend the Assistant Secretary, Office of Information and Technology, implement controls to stabilize the functionality requirements process and enforce software “code freeze” during the Veterans Service Network software development process.
7 We recommend the Under Secretary for Benefits implement controls to stabilize the functionality requirements process and enforce software “code freeze” during the Veterans Service Network software development process.
8 We recommend the Assistant Secretary, Office of Information and Technology, implement full testing of all supplemental software releases and emergency software changes to identify and remediate functionality defects before Veterans Service Network applications are installed for production.
9 We recommend the Assistant Secretary, Office of Information and Technology, implement controls to ensure that software transmittal processes provide accurate and up-to-date system documentation and software installation packages for pre-production testing.
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| 08-02679-134 | Audit of VA's Management of Information Technology Capital Investments | Audit | ||
1 We recommend that the Acting Assistant Secretary for Information and Technology establish management controls that ensure future Exhibit 300s are submitted in accordance with OMB requirements.
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2 We recommend that the Acting Assistant Secretary for Information and Technology develop a comprehensive written plan with measurable goals, objectives, milestones, and responsibilities.
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3 We recommend that the Acting Assistant Secretary for Information and Technology establish a dedicated team to implement OI&T's comprehensive written plan.
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4 We recommend that the Acting Assistant Secretary for Information and Technology clearly define the roles of the IT governance boards responsible for providing oversight and management of VA IT.
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5 We recommend that the Acting Assistant Secretary for Information and Technology establish the criteria IT governance boards will use to select, review, and assess IT capital investments.
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| 06-02238-163 | Review of Issues Related to the Loss of VA Information Involving the Identity of Millions of Veterans | Administrative Investigation | ||
1 Take whatever administrative action deemed appropriate concerning the individuals involved in the appropriate and untimely handling of the notification of stolen VA data.
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2 Establish one clear, concise VA policy on safeguarding protected information when stored or not stored in VA automated systems, ensure policy is readily available, and employees held accountable.
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3 Modify the mandatory Cyber Security and Privacy Awareness training to identify and provide a link to all applicable laws and VA policy.
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4 We recommend that the Secretary ensure that all position descriptions are evaluated and have proper sensitivity level designations, that there is consistency nationwide for positions that are similar in nature or have similar access to VA protected information and automated systems, and that all required background checks are completed in a timely manner.
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5 Establish VA-wide policy for contracts for services that requires access to protected information, ensures contractor personnel held to same standards, and information is safeguarded.
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6 Establish VA policy and procedures that provide clear, consistent criteria for reporting, investigating, and tracking incidents of loss, theft, or potential disclosure of protected information.
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| 04-00018-155 | Audit of the Veterans Health Administration's Acquisition of Medical Transcription Services | Audit | ||
1 The OIG recommends the CO seek a reduction of $10,842,681.30 to the proposed contract amounts by negotiating the recommended amounts identified in table 1.
Closure Date:
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14903