Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-02157-106 | Former Orlando VA Medical Center Executive Violated Ethics Rules | Administrative Investigation | ||
1 The Veterans Health Administration chief operating officer establishes a written policy or procedure to reasonably ensure that potential conflicts of interest or appearance of partiality concerns involving VHA employees are identified and remediated before contractor presentations to Veterans Integrated Service Network or facility leaders.
2 The Veterans Integrated Service Network 8 director confirms that VA has initiated the process to seek recoupment of the critical skill incentive paid by VA to Ms. Skala that was attributable to a service period that she did not complete due to her retirement.
3 The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness directs a review to determine whether any VHA employee ranked GS‑15 or above awarded a critical skill incentive has left VA before completing their required service obligation, and, if so, whether VA has established a debt and initiated recoupment in the amount of the CSI attributable to the uncompleted period, and takes further corrective actions as warranted.
| ||||
| 24-01566-100 | Deficiencies in Trainee Onboarding, Physician Oversight, and a Root Cause Analysis at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 The Overton Brooks VA Medical Center Director reviews and monitors compliance with Veterans Health Administration health professions trainee onboarding requirements, and takes action as indicated.
2 The Overton Brooks VA Medical Center Director makes certain that oversight of the intensive care unit physician credentialing and privileging process is completed prior to physicians being scheduled and providing patient care, and monitors compliance.
3 The Overton Brooks VA Medical Center Director ensures root cause analyses are completed according to Veterans Health Administration policy including team composition, root cause analysis process steps, and timeliness.
4 The Under Secretary for Health evaluates the additional root cause analysis concurrence step used within Veterans Health Administration medical centers to ensure alignment with National Center for Patient Safety guidance, and takes action as indicated.
| ||||
| 24-00645-84 | Integrated Financial and Acquisition Management System Interface Development Process Needs Improvement | Audit | ||
1 Incorporate all business-essential processes and related interfaces, as defined by product owners, during validation sessions, user acceptance testing, or equivalent procedures to accurately present system capability.
2 Enhance the test plan to incorporate a more robust, risk-based testing process that incorporates user-testing requirements for functional and nonfunctional business-essential processes related to interfaces.
3 Develop a process to confirm with affected administrative offices whether they are aware of needed changes to test environments and that they have sufficiently executed them before interface test events.
4 Develop a method to evaluate whether test deficiencies necessitate changes to the deployment schedule to ensure deficiencies are properly addressed before wave go-live and implement these changes.
| ||||
| 24-01330-29 | Improper Sharing of Sensitive Information on Cloud-Based Collaborative Applications | Review | ||
1 Take corrective actions to ensure that facilities and programs remove unauthorized sensitive information from collaborative application sites.
2 Direct facilities and programs to standardize SharePoint administration, inventory and consolidate their SharePoint sites, and enforce the recommended architecture to better control access and content at the facility or program level.
Closure Date:
3 Implement enforcement mechanisms to ensure that facilities and programs are following standardized processes to secure SharePoint and Teams sites.
Closure Date:
4 Expand roles and responsibilities of facility and program information system security officers and privacy officers to include the routine review of SharePoint and Teams site permissions and content.
5 Implement automated tools and policies, supported with training, to enable the timely and routine detection and correction of improper sharing and unauthorized content throughout VA.
6 Mandate standardized training for SharePoint administrators and owners to clarify and reinforce data security requirements.
Closure Date:
| ||||
| 24-00990-99 | Delayed Diagnosis and Treatment for a Patient’s Lung Cancer and Deficiencies in the Lung Cancer Screening Program at the VA Eastern Kansas Healthcare System in Topeka and Leavenworth | Hotline Healthcare Inspection | ||
1 The VA Eastern Kansas Healthcare System Director ensures the chief of primary care reviews, strengthens, and implements system Patient Aligned Care Team processes for tracking and following up on community care consults ordered, particularly diagnostic consults, to verify patients receive care and to review and act upon consult results, as clinically indicated.
2 The VA Eastern Kansas Healthcare System Director reviews institutional disclosures conducted by the system over the past 12 months, including the patient’s institutional disclosure, and ensures these disclosures fully adhere to Veterans Health Administration Directive 1004.08, Disclosure of Adverse Events to Patients, October 31, 2018, including documenting the details of the adverse event and discussion points of the disclosure, and takes action needed to remediate disclosures that do not meet these standards.
3 The VA Eastern Kansas Healthcare System Director ensures community care staff make the required three attempts to obtain patients’ community care records within 90 days of completed appointments, and monitors for compliance.
4 The VA Eastern Kansas Healthcare System Director collaborates with the Kansas City VA Medical Center Director to review the frequency and circumstances of community care records being sent to the incorrect VA facility, develops, and implements a process for ensuring community care records are delivered to the correct ordering VA facility, educates staff on the process, and monitors for compliance.
5 The Under Secretary for Health establishes and monitors compliance with a process that ensures the Veterans Health Administration ordering provider receives urgent non-life-threatening abnormal test results from care obtained in the community, such as the diagnostic positron emission tomography scan results described in this report, within a time frame that allows timely attention and appropriate action to be taken.
6 The Veterans Integrated Service Network Director, in conjunction with the Veterans Health Administration National Center for Lung Cancer Screening Program Office, evaluates the VA Eastern Kansas Healthcare System’s Lung Cancer Screening Program to ensure operational adherence to the Lung Cancer Screening Program requirements, and takes action as needed.
| ||||
| 24-01153-52 | The PACT Act Has Complicated Determining When Veterans’ Benefits Payments Should Take Effect | Review | ||
1 Create a job aid for claims processors on how to determine the correct effective date for PACT Act–related claims.
2 Remove the outdated effective date builder from the Veterans Benefits Administration’s internal job aids page.
Closure Date:
3 Continue updating the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when the Veterans Benefits Administration receives an intent to file.
Closure Date:
4 Update the Veterans Benefits Management System-Rating system’s effective date builder to add functionality that applies liberalizing laws on claims when a veteran’s service connection is based on a toxic exposure risk activity.
Closure Date:
5 Evaluate PACT Act refresher training by monitoring the results to assess the effectiveness of the training.
Closure Date:
6 Correct all processing errors on cases identified by the review team and report the results to the Office of Inspector General.
| ||||
| 24-02356-58 | A Prohibited Default in the Clinically Indicated Date Field Limited Some Veterans’ Eligibility for Community Care at the Omaha VA Medical Center in Nebraska | Review | ||
1 Issue a memorandum that clarifies that automatically prepopulating the clinically indicated date field of a consult is prohibited (barring officially recognized exceptions) and that it should be entered manually.
Closure Date:
2 Determine whether any administrative action should be taken with respect to the conduct of the medical facility director and the chief of staff of the Omaha VA Medical Center.
3 Direct the medical facility director to educate and train those involved with consults on the process, including how to customize the clinically indicated date to reflect the date of care agreed to by the provider and the veteran. The training should be mandatory, its contents should comply with national policy, and its frequency should be determined by the medical facility director.
4 Assess the actions the medical facility has taken to review the consults that were potentially affected by the 29-day default in the clinically indicated date field and ensure veterans received the care they needed.
| ||||
| 24-00595-93 | Healthcare Facility Inspection of the VA Western Colorado Healthcare System in Grand Junction | Healthcare Facility Inspection | ||
1 The OIG recommends executive leaders evaluate the toxic exposure screening process and develop a sustainable action plan to ensure staff complete secondary screenings.
2 The OIG recommends executive leaders ensure facility staff conduct all required monthly and annual fire extinguisher inspections, document the completion date and results, and report compliance rates to the Comprehensive Environment of Care Committee.
3 The OIG recommends executive leaders ensure facility staff complete preventive maintenance inspections for all medical equipment.
4 The OIG recommends executive leaders ensure facility staff develop and implement processes to properly disinfect wheelchairs, remove dust from ceiling vents, and repair walls.
5 The OIG recommends executive leaders ensure facility staff keep clean and dirty equipment and supplies separated in storage areas and ensure staff can access medical equipment when needed.
6 The OIG recommends executive leaders ensure facility staff use video monitors for patient safety purposes only and limit them to staff directly involved in the patient’s care.
7 The OIG recommends Veterans Integrated Service Network leaders ensure facility executive leaders provide effective oversight of the environment of care program.
8 The OIG recommends executive leaders ensure quality management staff implement a system-wide process to monitor the effectiveness of patient notification of all urgent, noncritical test results.
| ||||
| 22-02369-48 | Independent Audit Report on a Transportation Company’s Billing Practices Under a VA Healthcare System Contract | Audit | ||
1 Seek the opinion of the Office of General Counsel on whether the identified potential overbillings could or should be recouped.
| ||||
| 24-00295-49 | VHA Should Improve Monitoring of Underground Storage Tanks to Minimize Environmental and Health Risks at VA Medical Facilities | Audit | ||
1 As a part of the annual certification process of the Capital Asset Inventory, the executive director of the Office of Asset Enterprise Management should provide guidance on underground storage tank entries to ensure these assets are recorded with consistent identifying terminology in asset identification fields and with the appropriate real property predominant use code: code 40, “storage (other than buildings).”
2 Ensure Veterans Integrated Service Network officials fulfill their oversight responsibilities found in Veterans Health Administration Directive 1811 requiring VA medical facilities maintain a current inventory of underground storage tanks, inclusive of all associated equipment and component levels.
3 Ensure the assistant under secretary for health for support updates the responsibility section in Veterans Health Administration Directive 7707 to ensure that the responsibilities of VA medical facility directors include appropriate designation of staff and training for environmental regulatory requirements.
4 Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 to ensure facility compliance with federal, state, and local codes, laws, and regulations—including monitoring and addressing underground storage tank alarms promptly to confirm a release has not occurred.
5 Ensure Veterans Integrated Service Networks are fulfilling responsibilities in Veterans Health Administration Directive 1811 for work order (unplanned corrective maintenance) tracking from creation through completion in the approved maintenance management system—to include underground storage tank and associated component-level equipment failures or deficiencies identified in regulatory agencies’ inspections.
6 Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling responsibilities in Veterans Health Administration Directive 7707 to ensure regulatory compliance deficiencies are promptly reviewed, corrective actions are developed, and issues are tracked through completion to satisfactorily address environmental compliance.
7 Confirm VA medical facility directors and Veterans Integrated Service Network directors are fulfilling their oversight responsibilities found in Veterans Health Administration Directive 7707 to ensure all required federal, state, and local regulatory agencies’ inspections of underground storage tanks are recorded in the Veterans Health Administration issue brief tracking system.
| ||||
14903