Recommendations
716
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00589-17 | Healthcare Facility Inspection of the VA Northport Healthcare System in New York | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure staff secure all medications and the supplies used to administer medications in the Emergency Department.
2 The OIG recommends facility leaders confirm staff are knowledgeable about how the lobby kiosks function to assist veterans with sensory impairments.
Closure Date:
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| 24-00586-11 | Healthcare Facility Inspection of the Durham VA Health Care System in North Carolina | Healthcare Facility Inspection | ||
1 The OIG recommends that executive leaders ensure staff store all high-alert medications in a secure or locked area.
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2 The OIG recommends that executive leaders ensure staff follow their processes to prevent the storage of expired medical supplies and that supply areas remain clean.
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3 The OIG recommends that executive leaders ensure staff keep the facility free of temporary signage that may interfere with cleaning and disinfection processes.
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4 The OIG recommends that the patient safety manager confirms staff enter known patient safety events into the Joint Patient Safety Reporting system for use in the initial assessment of these events.
Closure Date:
5 The OIG recommends that executive leaders ensure quality management staff implement an oversight process to validate providers’ compliance with patient communication and follow-up for urgent, noncritical abnormal test results.
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6 The OIG recommends executive leaders evaluate options to improve safety at the informal crossing area near parking garage B.
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7 The OIG recommends that executive leaders ensure all directories are accurate and provide specific details so veterans can easily navigate the facility.
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8 The OIG recommends that executive leaders implement additional features to aid veterans with sensory impairments to navigate the facility.
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9 The OIG recommends that executive leaders ensure staff train patient escorts on how to effectively communicate with sensory-impaired veterans.
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10 The OIG recommends that executive leaders ensure the Comprehensive Environment of Care Committee reviews environment of care deficiencies for trends and opportunities for improvement.
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11 The OIG recommends that executive leaders ensure staff review patient safety events for trends and system vulnerabilities and implement process improvement actions to prevent future occurrences.
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| 24-00118-01 | Staff Incorrectly Processed Claims When Denying Veterans’ Benefits for Presumptive Disabilities Under the PACT Act | Review | ||
1 Update VA’s Adjudication Procedures Manual on when personnel should request medical disability examinations and opinions.
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2 Reduce examination and medical opinion overdevelopment by establishing a plan to continue the development of examination request tools and evaluate the effectiveness of these efforts for any future enhancements.
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| 23-03517-230 | Survivors Did Not Always Receive Accurate Retroactive Benefits for Dependency and Indemnity Compensation Claims Reopened Under the PACT Act | Review | ||
1 Correct the two errors involving prematurely denied Dependency and Indemnity Compensation claims.
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2 Conduct a file review of the reopened Dependency and Indemnity Compensation claims granted under the PACT Act from January 1 through August 31, 2023, and take appropriate actions to ensure monetary benefits and notification letters are accurate.
3 Consider whether modifications could be made to the reevaluation request process consistent with the PACT Act and related regulations and, should this result in a policy change, consult with the VA Office of General Counsel.
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| 23-02682-09 | Veterans Health Administration Initiated Toxic Exposure Screening as Required by the Promise to Address Comprehensive Toxics (PACT) Act but Improvements Needed in the Training Process | National Healthcare Review | ||
1 The Under Secretary for Health ensures Veterans Health Administration leaders assess reasons for noncompliance with training requirements and takes action as warranted.
2 The Under Secretary for Health evaluates whether toxic exposure screening is negatively affecting primary care workload and takes action to mitigate as needed.
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| 23-00547-187 | VBA Did Not Ensure Employees Sent Some Letters Using Its Package Manager Application | Review | ||
1 Implement and periodically monitor the effectiveness of a plan to provide oversight for unsent packages in the Package Manager application.
2 Implement a plan to address existing unsent packages in the Package Manager application.
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| 24-01232-02 | Inspection of Information Security at the Health Eligibility Center in Atlanta, Georgia | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure all vulnerabilities are identified and that plans of action and milestones are created for vulnerabilities that cannot be mitigated by VA deadlines.
2 Implement a more effective system life-cycle process to ensure network devices are running authorized software and operating systems that are configured to approved baselines and free of vulnerabilities.
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3 Ensure all file systems holding veteran information are encrypted in accordance with NIST and VA policy requirements.
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4 Maintain an accurate inventory of personnel with key access to the facility.
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5 Enable improved audit logging capability to monitor administrator access to sensitive information hosted on the Workload Reporting and Productivity Assessing file server.
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| 23-03526-07 | Heart Transplant Program Review: Facility Leaders Failed to Ensure a Culture of Safety and the Section Chief Engaged in Unprofessional Conduct at the Richmond VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Richmond VA Medical Center Director ensures completion of a clinical review of patient 2’s cardiothoracic surgical episode of care and takes action as appropriate.
Closure Date:
2 The Under Secretary for Health ensures that consideration to reactivate the heart transplant program at the Richmond VA Medical Center includes a comprehensive analysis of transplant referral volume, leadership competency, and transplant team proficiency.
3 The Under Secretary for Health ensures that VA Mid-Atlantic Health Care Network and Richmond VA Medical Center leaders conduct a rigorous surveillance of quality measures if the heart transplant program is reactivated and emphasize safely meeting program target volumes to maintain clinical experience.
4 The Richmond VA Medical Center Director ensures the chief of surgery conducts a review of the cardiothoracic section chief’s unprofessional behaviors and develops a plan to address complaints.
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5 The Richmond VA Medical Center Director ensures surgical leaders review cardiothoracic staff’s concerns and take action to create a culture of safety, and considers the use of resources such as the National Center for Organization Development.
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6 The VA Mid-Atlantic Health Care Network Director develops a process for ensuring VA Mid-Atlantic Health Care Network staff provide timely and complete responses to facility leaders’ requests for clinical care reviews.
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| 23-02890-209 | VBA’s and NCA’s Personnel Suitability Programs Need Improved Governance | Audit | ||
1 Execute the compliance plan for the Veterans Benefits Administration’s personnel suitability program.
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2 Ensure the Veteran Benefits Administration’s personnel suitability program oversight verifies background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
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3 Establish a plan to ensure robust oversight of the National Cemetery Administration’s personnel suitability program that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
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4 Evaluate resource requirements for the personnel suitability program to ensure that all personnel suitability requirements are being met.
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| 24-00386-265 | Inspection of Select Vet Centers in Pacific District 5 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Everett and Walla Walla Vet Center Directors collaborate with the support VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
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2 District leaders and the Eugene Vet Center Director determine reasons for noncompliance with completing four hours of external clinical consultation for clinically complex cases per month, ensure a process is implemented, and monitor compliance.
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3 District leaders and the Anchorage, Eugene, and Everett Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
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4 District leaders and the Anchorage, Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
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5 District leaders and Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with fire or safety annual inspection, ensure completion, and monitor compliance.
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6 District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with monthly fire extinguisher inspections, ensure completion, and monitor compliance.
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7 District leaders and the Eugene and Everett Vet Center Directors determine reasons for noncompliance with annual fire extinguisher servicing, ensure completion, and monitor compliance.
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8 District leaders and the Eugene Vet Center Director determine reasons for noncompliance with having an automated external defibrillator located on-site and ensure compliance with the requirement.
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9 District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
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10 District leaders and the Everett and Walla Walla Vet Center Directors determine reasons for noncompliance with building evacuation plans posted in a communal area for staff and visitors and ensure compliance with the requirement.
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11 District leaders and the Eugene and Walla Walla Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
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12 District leaders and the Eugene, Everett, and Walla Walla Vet Center Directors determine reasons for noncompliance with a desktop reference sheet outlining steps for ancillary office staff to follow in case of a suicidal or homicidal client, ensure completion, and monitor compliance.
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11259