Recommendations
1282
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-00515-299 | Inspection of the VA Regional Office Phoenix, Arizona | Review | ||
1 We recommended the Phoenix VA Regional Office Director implement a plan to ensure Rating Veterans Service Representatives follow second signature policy requirements for special monthly compensation rating decisions and perform an effective review.
Closure Date:
2 We recommended the Phoenix VA Regional Office Director implement a plan to improve the second signature review process for special monthly compensation rating decisions.
Closure Date:
3 We recommended the Phoenix VA Regional Director implement a plan to prioritize proposed rating reduction cases for completion at the end of the due process time period.
Closure Date:
4 We recommended the Phoenix VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is accurate.
Closure Date:
5 We recommended the Phoenix VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.
Closure Date:
6 We recommended the Phoenix VA Regional Office Director provide training to congressional liaisons on special controlled correspondence to ensure all documents are included in the electronic record in accordance with current Veterans Benefits Administration guidance.
Closure Date:
7 We recommended the Phoenix VA Regional Office Director update the office’s local procedures relating to special controlled correspondence in accordance with current Veterans Benefits Administration procedures.
Closure Date:
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| 17-00602-342 | Healthcare Inspection – Quality of Care Concerns in Thoracic Surgery, Bay Pines VA Healthcare System, Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that focused professional practice evaluations review criteria are sufficient to evaluate the privilege-specific competence for thoracic surgeons.
Closure Date:
2 We recommended that the System Director ensure that ongoing professional practice evaluation reviews are conducted by providers with training and privileges similar to those of the provider under review.
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| 16-00577-335 | Clinical Assessment Program Review of the VA Northern Indiana Health Care System, Fort Wayne, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers ensure clean bed frames in patient care areas and monitor compliance.
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3 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
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4 We recommended that the facility designate a physician anticoagulation program champion.
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5 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
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6 We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
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7 We recommended that the facility collect and report data on patient transfers out of the facility.
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8 We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
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9 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
Closure Date:
10 We recommended that for patients transferred out of the facility, employees enter a progress note titled, “Inter-facility Transfer Notes for Individual Disciplines.”
Closure Date:
11 We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
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12 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
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14 We recommended that the facility’s Disruptive Behavior Committee include a senior clinician chair and the Patient Safety Manager and/or Risk Manager and that the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
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15 We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
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16 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
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17 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
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18 We recommended that that the Medical Executive Committee discuss and document its approval of the use of another facility’s physicians for teledermatology services.
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19 We recommended that the facility obtain teledermatology physicians’ professional practice evaluation information from the providing facility.
Closure Date:
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| 16-00555-337 | Clinical Assessment Program Review of the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility consistently take action when data analyses indicated problems or opportunities for improvement and evaluate the actions for effectiveness in peer review and Focused Professional Practice Evaluations and that facility managers monitor compliance.
Closure Date:
2 We recommended that the facility Chief of Staff ensure that all required practitioners are designated as members of the medical staff.
Closure Date:
3 We recommended that facility managers ensure the access log for the Huntingdon County VA Clinic information technology network room includes all required elements to document access and that facility managers monitor compliance.
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4 We recommended that facility managers implement a process to protect personally identifiable information on laboratory specimens at the Huntingdon County VA Clinic and that facility managers monitor compliance.
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5 We recommended that the facility designate a physician anticoagulation program champion.
Closure Date:
6 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
7 We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
Closure Date:
9 We recommended that facility managers ensure integration of the community nursing home program into its quality improvement program.
Closure Date:
10 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and that facility managers monitor compliance.
Closure Date:
11 We recommended that a VA physician order or approve all therapies that are at VA expense.
Closure Date:
12 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that training is documented in employee training records.
Closure Date:
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| 16-00355-296 | Audit of the VHA's Health Care Enrollment Program at Medical Facilities | Audit | ||
1 We recommended the Acting Under Secretary for Health develop standardized national policy and procedures for the health care enrollment program at VA medical facilities.
Closure Date:
2 We recommended the Acting Under Secretary for Health implement national oversight of the health care enrollment program to continually review operations and performance of VHA medical facilities.
Closure Date:
3 We recommended the Acting Under Secretary for Health provide mandatory and standardized training on eligibility and enrollment to ensure health care applications are processed accurately and timely.
Closure Date:
4 We recommended the Acting Under Secretary for Health develop and execute a process to distinguish new applications for health care enrollment in VistA from other registration data.
Closure Date:
5 We recommended the Acting Under Secretary for Health implement a plan to correct current data integrity issues in VistA to improve the accuracy and timeliness of enrollment data.
Closure Date:
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| 16-05468-282 | Inspection of the VA Regional Office Atlanta, Georgia | Review | ||
1 We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases are appropriately distributed to the most qualifiedpersonnel.
Closure Date:
2 We recommended the Atlanta VA Regional Office Director implement aplan to monitor the effectiveness of training on higher-level SpecialMonthly Compensation and Ancillary Benefits.
Closure Date:
3 We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases receive an accurate, signed second-level review.
Closure Date:
4 We recommended the Southeast District Director implement a plan toensure the Atlanta VA Regional Office Director provides oversight andprioritization of proposed rating reductions claims for completion at theend of the due process period.
Closure Date:
5 We recommended that the Atlanta VA Regional Office Director ensureclaims assistants receive all systems compliance related training relevantto claims establishment.
Closure Date:
6 We recommended that the Atlanta VA Regional Office Directorimplement a plan to modify the quality review checklist on claimsestablishment to include claim label and claimed issue classification indicators for all claims.
Closure Date:
7 We recommended the Atlanta VA Regional Office Director implement aplan to ensure claims processing staff properly establish and maintainend product 500s for control of special controlled correspondence.
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8 We recommended the Atlanta VA Regional Office Director implement aplan to ensure staff adhere to Veterans Benefits Administration policyand acknowledge special controlled correspondence with a timely interimor full response.
Closure Date:
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| 16-04626-280 | Inspection of the VA Regional Office, New Orleans, Louisiana | Review | ||
1 We recommended the New Orleans VA Regional Office Directorimplement a plan to assess the effectiveness of secondary reviews forSpecial Monthly Compensation and ancillary benefits claims.
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2 We recommended the Continental District Director implement a plan toensure oversight and prioritization of proposed rating reduction cases forcompletion at the end of the due process time period at the New OrleansVA Regional Office.
Closure Date:
3 We recommended the New Orleans VA Regional Office Director ensureclaims assistants receive all mandatory annual training on claimsestablishment procedures.
Closure Date:
4 We recommended the New Orleans VA Regional Office Directorimplement a plan to strengthen the review process to assess all elementsrequired when establishing claims in the electronic record.
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5 We recommended the New Orleans VA Regional Office Directorprovide training to Legal Administrative Specialists responsible forprocessing controlled correspondence and monitor the effectiveness ofthe training.
Closure Date:
6 We recommended the New Orleans VA Regional Office Director ensureLegal Administrative Specialists adhere to Veterans Benefits Administration policy when processing special controlled correspondence.
Closure Date:
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| 15-02583-256 | Review of Alleged Delay of Care and Scheduling Issues at the VAMC in West Palm Beach, FL | Audit | ||
1 We recommended the Director of the West Palm Beach VA Medical Center ensure recruitment efforts are progressing to fulfill cardiology clinic vacancies and that there are sufficient cardiologists for the needs of the Medical Center.
Closure Date:
2 We recommended the Director of the West Palm Beach VA Medical Center ensure all scheduling staff are trained on the requirement to reschedule appointments canceled by the clinic within 14 days of the original appointment date.
Closure Date:
3 We recommended the Director of the West Palm Beach VA Medical Center ensure schedulers are using the clinically indicated or preferred appointment dates when scheduling appointments.
Closure Date:
4 We recommended the Director of the West Palm Beach VA Medical Center ensure supervisors perform the required number of scheduling audits for each scheduler as required by VAMC policy.
Closure Date:
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| 16-00589-264 | Audit of VHA's Consolidated Patient Account Center Controls To Prevent Improper Billings for Service-Connected Conditions | Audit | ||
1 We recommended the Under Secretary for Health require Consolidated Patient Account Centers review a statistical sample of bills issued during fiscal years 2015 and 2016 for the treatment of service-connected veterans to identify erroneously billed amounts that require refunds, and use these results to address internal control deficiencies and assess what additional efforts can be taken to identify and refund erroneously billed amounts.
Closure Date:
2 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to provide billing staff read-only access to the Veterans Benefits Management System to identify potential service-connected bills that require review by Revenue Utilization Review nurses.
Closure Date:
3 We recommended the Under Secretary for Health require Consolidated Patient Account Center management establish oversight procedures to review statistical samples of prescriptions prior to generating bills to veterans and to address any identified systemic or facility-specific billing problems.
Closure Date:
4 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise quality assurance reviews to include reviews of pharmacy bills and evaluate whether Revenue Utilization Review nurses correctly validate or make service-connection determinations for veterans’ medical treatment based upon staffing and workload.
Closure Date:
5 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to revise policy and procedure to require Consolidated Patient Account Center staff to adequately provide and document training for VA medical facility staff regarding specific service-connection determination errors.
Closure Date:
6 We recommended the Under Secretary for Health require Consolidated Patient Account Center management to track and monitor incorrect medical provider service-connection determinations and coordinate training to ensure identified issues are appropriately addressed.
Closure Date:
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| 16-02454-250 | Review of VA’s Readiness To Implement the Digital Accountability and Transparency Act | Audit | ||
1 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Establish milestones to monitor VA’s system modernization efforts. Coordination with the shared service provider should continue to incorporate current and upcoming DATA Act requirements to ensure that they will be met going forward.
Closure Date:
2 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Obtain procurement and grants management system capability that is integrated with the financial system as part of VA’s transition to a shared service provider to the extent feasible.
Closure Date:
3 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Improve communication with, and accountability of, administrations and offices and their points of contact who are responsible for providing data and documentation. Accountability should include timely, complete, and accurate submissions to the Project Management Office.
Closure Date:
4 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Continue working with the points of contact to ensure program information for all funds is submitted as required.
Closure Date:
5 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Identify internal controls and develop standard operating procedures for the processes used to obtain, extract, classify, and summarize data from VA’s financial and management systems to comply with the DATA Act schema.
Closure Date:
6 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
In conjunction with VA’s component organizations, perform an assessment of how business, accounting, and payment processes interact with one another for the purpose of establishing relevant policies and procedures to improve VA’s data quality. This assessment should include VA’s subsidiary systems and their interface status with the general ledger system, that is Financial Management System.
Closure Date:
7 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Ensure complete reconciliations are performed between the subsidiary and general ledger systems. Differences should be researched and resolved to improve data quality.
Closure Date:
8 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Continue to work on minimizing the use of the Management Information Exchange to record journal vouchers that are not linked to obligation and expenditure data by object class or program activity, or devise a mechanism to track such information when recording Management Information Exchange journal vouchers.
Closure Date:
9 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Perform reconciliations between VA’s procurement systems (Electronic Contract Management System and Integrated Funds Distribution, Control Point Activity, Accounting and Procurement system) and Financial Management System to ensure consistency, accuracy, and completeness of financial and procurement data.
Closure Date:
10 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Provide resources for data storage capabilities to improve auditability of data. Specifically, VA should establish a data storage mechanism such as a shared drive to store data received from points of contact or developed internally by the Project Management Office. Such information should be secured, readily available for analysis and requests, validated, and auditable.
Closure Date:
11 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Ensure proper segregation of duties between staff responsible for processing data for submission to the data broker and staff responsible for validating the accuracy and completeness of data prior to submission to the data broker.
Closure Date:
12 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Provide necessary resources to the VA DATA Act Project Management Office to ensure that the office can coordinate the data inventory, mapping, and validation for the required DATA Act Schema data elements.
Closure Date:
13 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Require administration points of contact to respond timely to Project Management Office data requests to ensure that the data elements can be inventoried, mapped, and validated and that gap analyses are performed thoroughly.
Closure Date:
14 We recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Use the data inventory and mapping to support VA’s move to a shared service provider and ensure full compliance with the DATA Act.
Closure Date:
15 In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Establish procedures for data edits and validations to ensure that DATA Act submissionsare accurate and complete. At a minimum, management should selectively test internalcontrols related to the preparation of data submissions.
Closure Date:
16 In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Assess the impact of the internal control weaknesses, as reported by VA’s financialstatement audit, on DATA Act data, and develop alternative processes to address data quality issues.
Closure Date:
17 In addition to recommendations made in Findings Number 1 and Number 2, we recommend that the Acting Assistant Secretary for Management and Acting Chief Financial Officer:
Continue to maintain communication with the Office of Management and Budget andTreasury regarding VA’s data reporting limitations and progress, and document suchcommunication.
Closure Date:
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11259