Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00551-64 | Healthcare Facility Inspection of the VA Washington DC Healthcare System | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalk between the patient parking garage and main entrance until completion.
2 The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.
3 The OIG recommends facility leaders implement actions to correct the electrical issue in the Emergency Department Main 2 area and mitigate the risk until it is resolved.
Closure Date:
4 The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.
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| 24-02277-69 | Continued Sterile Processing Services Deficiencies and Facility Leaders’ Failures at the Carl Vinson VA Medical Center in Dublin, Georgia | Hotline Healthcare Inspection | ||
1 The Carl Vinson VA Medical Center Director ensures applicable staff, such as Sterile Processing Services staff and end users of reusable medical devices, comply with procedures regarding the identification of and disposition of nonconforming surgical instruments.
2 The Carl Vinson VA Medical Center Director confirms operating room staff completes training regarding the recognition of and procedures for nonconforming surgical instruments.
3 The VA Southeast Network Director establishes a comprehensive strategy to review patients who may have been affected by the approximately 800 nonconforming surgical instruments to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of disclosures.
Closure Date:
4 The VA Southeast Network Director evaluates whether administrative action is warranted for employees regarding Sterile Processing Services deficiencies at the Carl Vinson VA Medical Center, and takes action as appropriate.
5 The VA Southeast Network Director provides consultation and oversight to the Carl Vinson VA Medical Center’s Sterile Processing Services to ensure implementation of facility-level action plans and sustainability of identified outcomes.
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| 24-00592-60 | Healthcare Facility Inspection of the VA Dublin Healthcare System in Georgia | Healthcare Facility Inspection | ||
1 The OIG recommends that facility leaders review and correct any outdated navigational signage.
Closure Date:
2 The OIG recommends facility leaders define and assign roles and responsibilities to toxic exposure screening navigators and ensure program oversight.
3 The OIG recommends the Director ensures staff keep patient care areas safe and clean.
4 The OIG recommends the Director ensures biohazard storage areas display proper signage, have appropriate hand-washing supplies and equipment available, and do not contain housekeeping supplies.
5 The OIG recommends the Associate Director ensures staff identify one or more facility environment of care trends and establish a performance improvement plan, including outcome measures, to address them.
6 The OIG recommends that facility leaders continue to develop and implement administrative processes to ensure ordering providers promptly communicate and document test results.
7 The OIG recommends that facility leaders ensure staff maintain and reference current VHA requirements and update facility-level policies and standard operating procedures to comply with them.
8 The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.
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| 24-00594-61 | Healthcare Facility Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.
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| 22-03076-65 | Ensuring Grantee Compliance with Veteran Care and Safety Requirements in Transitional Housing: Lessons Learned from San Diego | Administrative Investigation | ||
1 Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.
2 Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.
3 Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.
4 Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantee’s premises and any adverse health or safety inspection results or similar findings made concerning the grantee’s premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.
5 Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSD’s clinical treatment housing model.
Closure Date:
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| 24-01859-62 | Mental Health Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Mental Health Inspection Program | ||
1 The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.
Closure Date:
2 The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.
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3 The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.
Closure Date:
4 The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.
5 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.
Closure Date:
6 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.
7 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.
8 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.
Closure Date:
9 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.
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10 The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.
11 The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.
12 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.
Closure Date:
13 The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.
Closure Date:
14 The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.
15 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.
Closure Date:
16 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.
Closure Date:
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| 24-01827-57 | Healthcare Inspection VISN Summary Report: Evaluation of Practitioner Credentialing and Privileging for Fiscal Years 2023 to 2024 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes solo and two-deep practitioners’ professional practice evaluations in a timely manner.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network chief medical officers and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes Ongoing Professional Practice Evaluations of chiefs of staff in each facility in a timely manner.
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, reviews state licensing board reporting processes at the network level to ensure compliance with Veterans Health Administration policy.
4 The Under Secretary for Health, in conjunction with the Veterans Integrated Service Network 8 Director, ensures the Chief Medical Officer oversees each facility’s annual self-assessment and confirms responses reflect accurate data.
Closure Date:
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| 23-00748-28 | Community Care Network Outpatient Claim Payments Mostly Followed Contract Rates and Timelines, but VA Overpaid for Dental Services | Audit | ||
1 Make sure the Office of Integrated Veteran Care develops contract language and/or maximum allowable rates to limit reimbursements that do not have a Medicare or VA fee schedule rate for Community Care Network claims.
2 Ensure the Office of Integrated Veteran Care improves oversight of healthcare claim payments to prevent, identify, and recover overpayments in a more timely manner.
3 Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction, collaborate to extend the contracting officer’s representatives’ designated responsibilities to include monitoring of healthcare invoices.
4 Make sure the Office of Integrated Veteran Care considers including dental contract reimbursement language in the current and/or future contracts that is consistent with other contract healthcare reimbursement methodology to limit dental contract reimbursements, not to exceed the amount the third-party administrators pay the providers.
5 Make certain the Office of Procurement, Acquisition, and Logistics develops sufficient oversight and internal controls over the contract modification process to prevent program overpayments.
6 Require the Office of Veteran Integrated Care and the Office of Acquisition, Logistics, and Construction to collaborate to explore potential recovery of dental payments to Optum.
7 Ensure the Office of Integrated Veteran Care and the Office of Acquisition, Logistics, and Construction collaborate to establish oversight and internal controls for dental services provided through Community Care Network to prevent excessive reimbursements.
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| 24-01535-55 | Staff Mitigated the Impact of Appointment Cancellations in a Mental Health Clinic at the VA Northern Indiana Healthcare System in Fort Wayne | Hotline Healthcare Inspection | ||
1 The VA Northern Indiana Healthcare System Director evaluates the system clinic cancellation policy and Chief of Staff notification of urgent clinic cancellations and takes action as appropriate.
2 The VA Northern Indiana Healthcare System Director reviews short-notice clinical cancellations for social work mental health clinics, including the provider’s clinic, to evaluate patient impact and take actions as appropriate.
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| 24-00103-27 | Financial Efficiency Inspection of the VA Tampa Healthcare System | Financial Inspection | ||
1 Establish a plan to use VA’s cost accounting system information to identify additional ways to reduce costs, enhance efficiency, and inform business decisions as identified by VA financial policy.
2 Ensure the facility has a process to identify cost outliers, such as using the Intermediate Product Cost Outlier report to identify cost outliers that may occur at the healthcare system on a regular basis.
Closure Date:
3 Ensure healthcare system service lines review and update the national labor mapping tool to the Veterans Integrated Service Network managerial cost accounting team as required by VA financial policy to ensure workload is being captured correctly.
4 Ensure that healthcare system staff and responsible finance office staff review all open obligations to ensure balances are valid and should remain open or are closed in a timely manner as required by VA Financial Policy, “Obligations,” as updated in March 2024.
5 Ensure that the healthcare system uses appropriated funds in the manner intended by Congress, as required by the VA Financial Policy, “Obligations,” as updated in March 2024.
6 Consult with the Office of General Counsel and the Office of Acquisitions, Logistics, and Construction to determine whether a bona fide needs or other appropriations law violation occurred and, if any violations did occur, take appropriate remedial and preventive actions to address them.
7 Ensure cardholders comply with prior approval, segregation of duties, and record retention requirements as required by VA Financial Policy, volume 16, chapter 1B, “Government Purchase Card for Micro-Purchases.”
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8 Ensure cardholders and approving officials are aware of the requirement to review purchases and determine when it is in the best interest of the government to use strategic sourcing.
Closure Date:
9 Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package and ensure processes are in place to monitor performance metrics in accordance with Veterans Health Administration policy.
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10 Develop and maintain an effective standardized training program for new and current inventory staff and monitor the staff’s knowledge and skill level.
11 In coordination with the Strategic Acquisition Center, ensure that the Medical Surgical Prime Vendor facility-level contracting officer’s representatives and ordering officers are appointed and delegated properly and perform all required duties according to the scope and limitation of the designee’s authority.
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12 In coordination with the Strategic Acquisition Center, submit ratifications for any Medical Surgical Prime Vendor unauthorized commitments in accordance with the Federal Acquisition Regulation.
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14903