Recommendations
1151
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 11-01653-300 | Review of VHA's Management of Travel, Duty Stations, Salaries and Funds in the Procurement and Logistics Office | Audit | ||
1 We recommend the Chief Procurement and Logistics Officer
establish standard operating procedures to ensure that Procurement and Logistics Office approving officials only authorize travel upon obtaining the information needed to determine if travel is necessary.
Closure Date:
2 We recommend the Chief Procurement and Logistics Officer perform an annual review of all Procurement and Logistics Office employees to ensure they have correct duty station assignments.
Closure Date:
3 We recommend the Chief Procurement and Logistics Officer take
action to recoup salary overpayments or pay underpayments for
incorrect duty station assignments, as appropriate, in accordance with VA guidance.
Closure Date:
4 We recommend the Chief Procurement and Logistics Officer provide training annually to supervisors and financial officials regarding permitted versus restricted uses of the VA Supply Fund.
Closure Date:
5 We recommend the Deputy Assistant Secretary, Office of Acquisition and Logistics, in coordination with the Chief Procurement and Logistics Officer, establish a formal agreement outlining their respective management responsibilities and permitted versus restricted uses of the VA Supply Fund.
Closure Date:
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| 13-00090-346 | Evaluation of VHA Community Based Outpatient Clinics Fiscal Year 2012 | Comprehensive Healthcare Inspection Program | ||
1 Ensure that CBOC clinicians document foot care education provided to diabetic patients in the electronic health record.
Closure Date:
2 Ensure that CBOC clinicians perform risk assessments and document risk levels for diabetic patients in the electronic health record.
Closure Date:
3 Ensure that CBOC clinicians document referrals for preventative foot care, including foot wear, as clinically indicated, for patients with diabetes in the electronic health record.
Closure Date:
4 Ensure that CBOC managers establish a process to consistently link breast imaging and mammography results to the appropriate radiology mammogram or breast study order for all fee basis and contract patients.
Closure Date:
5 Ensure that CBOC managers establish a process to notify patients of normal mammogram results within the allotted timeframe and that notification is documented in the electronic health record.
Closure Date:
6 Ensure that service chiefs¿ documentation in VetPro reflects documents reviewed and the rationale for privileging or re-privileging CBOC providers.
Closure Date:
7 Ensure that facility Directors grant privileges consistent with the services provided at the CBOCs.
Closure Date:
8 Ensure that adequate resources and controls are in place to address deficiencies in the invoice validation process and to reduce the risk of overpayments.
Closure Date:
9 Ensure that the oversight of the contract acquisition process is compliant with VA Directives, including a thorough pre-award review and interim contract authority prior to contract approval.
Closure Date:
10 Ensure that all new CBOCs undergo the required contract approval processes prior to initiating operations.
Closure Date:
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| 13-00455-345 | Review of VA's Separately Priced Item Purchases for Training Conferences | Audit | ||
1 We recommended the Assistant Secretary for Human Resources and Administration consider discontinuing the use of assisted acquisition interagency agreements with the Office of Personnel Management for planning and conducting training conferences.
Closure Date:
2 We recommended the Assistant Secretary for Human Resources and Administration establish controls to ensure adequate visibility and oversight of separately priced items purchased through existing interagency agreements with the Office of Personnel Management, to include ensuring proposed purchases are approved in advance and determined to be for incidental items that support essential tasks developed under the interagency agreement.
Closure Date:
3 We recommended the Assistant Secretary for Human Resources and Administration ensure that VA receives and reviews invoices or receipts that support all separately priced items purchased through existing interagency agreements with the Office of Personnel Management prior to authorizing payment.
Closure Date:
4 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction update its policy to ensure a qualified individual with appropriate training in contracting is assigned to all existing interagency agreements with the Office of Personnel Management to monitor work performed on VA’s behalf.
Closure Date:
5 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction request the Office of Personnel Management review all bills associated with VA’s financial management training conferences, assess the results of the Office of Personnel Management’s review, and take steps to recover service fees paid to the prime vendor as a percentage of the cost of separately priced item purchases.
Closure Date:
6 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction assess the Office of Personnel Management’s oversight of separately priced items purchased through the interagency agreement used to fund, plan, and conduct VA’s financial management training conferences, and take steps to recover service fees paid to the Office of Personnel Management associated with inadequate oversight.
Closure Date:
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| 12-02387-343 | Audit of VA's Technology Acquisition Center Contract Operations | Audit | ||
1 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction ensure that contracting activities can adequately justify the use of exceptions to competition requirements in the Federal Acquisition Regulation when awarding Indefinite/Delivery Indefinite Quantity task orders.
Closure Date:
2 We recommended the Principal Executive Director for the Office of Acquisition, Logistics, and Construction require contracting activities to ensure program offices adequately document that goods and services cannot be acquired as conveniently or economically from a commercial source before awarding Interagency Acquisitions.
Closure Date:
3 We recommend the Principal Executive Director, Office of Acquisition, Logistics, and Construction build in steps into the Integrated Oversight Process to hold contracting officers accountable for preventing violations of Federal Acquisition Regulation competition requirements.
Closure Date:
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| 13-01974-337 | Combined Assessment Program Review of the Philadelphia VA Medical Center, Philadelphia, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently initiated and that results are reported to the PSB.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 We recommended that processes be strengthened to ensure that continued stay reviews are performed on at least 75 percent of patients in acute beds.
Closure Date:
4 We recommended that processes be strengthened to ensure that the Critical Care Committee reviews each code episode.
Closure Date:
5 We recommended that fire extinguisher signage be in place and operational in accordance with National Fire Protection Association Standards.
Closure Date:
6 We recommended that processes be strengthened to ensure that all designated hemodialysis employees receive annual bloodborne pathogens training.
Closure Date:
7 We recommended that chemicals stored on the hemodialysis unit be secured at all times and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that OR employees who perform IUS receive annual competency assessments.
Closure Date:
9 We recommended that processes be strengthened to ensure monthly inspections are completed in the inpatient pharmacy, the outpatient pharmacy, and the CLC vault and for the emergency drug cache and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person and a psychologist.
Closure Date:
11 We recommended that processes be strengthened to ensure that all non-HPC clinical staff who provide care to patients at the end of their lives receive end-of-life training.
Closure Date:
12 We recommended that the identified environmental hazards on the locked MH unit be corrected and that processes be strengthened to ensure that all environmental hazards on the locked MH units are identified and corrected.
Closure Date:
13 We recommended that processes be strengthened to ensure that all staff who work on locked inpatient MH units and MSIT members receive annual environmental hazards training.
Closure Date:
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| 13-02315-332 | Combined Assessment Program Review of the Edward Hines, Jr. VA Hospital, Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that ICC minutes reflect discussion of high-risk areas and actions implemented to address these areas.
Closure Date:
2 We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
Closure Date:
3 We recommended that processes be strengthened to ensure that inspectors consistently verify the three identified required drug destruction activities and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
5 We recommended that processes be strengthened to ensure that a contractor tuberculosis risk assessment is conducted prior to construction project initiation.
Closure Date:
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| 12-00366-339 | Audit of NCA's Contracting Practices | Audit | ||
1 We recommend the Under Secretary for Memorial Affairs ensure the Contracting Service establish procedures to ensure contracts are properly awarded according to the Federal Acquisition Regulations.
Closure Date:
2 We recommend the Under Secretary for Memorial Affairs ensure acquisition plans, market research, and evaluations of past performance are properly documented in the contract files.
Closure Date:
3 We recommend the Under Secretary for Memorial Affairs ensure Contracting Service establish procedures to ensure competitive procurement methods are used to the maximum extent possible.
Closure Date:
4 We recommend the Under Secretary for Memorial Affairs coordinate with the Office of Acquisition, Logistics, and Management to resolve Electronic Contract Management System issues to ensure system capabilities are fully used.
Closure Date:
5 We Recommend the Under Secretary for Memorial Affairs ensure Contracting Service fully implements the Integrated Oversight Process and ensure required contract reviews are conducted before awarding contracts.
Closure Date:
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| 13-00026-327 | Community Based Outpatient Clinic Reviews at Chalmers P. Wylie Ambulatory Care Center, Columbus, OH | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccine administration elements and that compliance is monitored.
Closure Date:
4 We recommended that managers develop a local policy for MH emergencies that reflects the CBOC’s capability and that staff is trained in the procedural steps of the MH emergency plan.
Closure Date:
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| 13-01855-336 | Healthcare Inspection – Quality of Care Issues, Erie VA Medical Center, Erie, PA, and VA Pittsburgh Healthcare System, Pittsburgh, PA | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director initiate a root cause analysis to evaluate system issues outlined in this report.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director evaluate the care of the patient discussed in this report with Regional Counsel for possible disclosure to the surviving family member(s) of the patient.
Closure Date:
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| 13-02316-322 | Combined Assessment Program Review of the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect discussion regarding deficiencies identified during EOC rounds and actions taken in response to those deficiencies.
Closure Date:
2 We recommended that processes be strengthened to ensure that employees wear gloves when in contact with patients on the hemodialysis unit and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that operating room employees who perform immediate use sterilization receive annual competency assessments.
Closure Date:
4 We recommended that processes be strengthened to ensure that RME SOPs are consistent with manufacturers' instructions and that RME is reprocessed in accordance with SOPs and manufacturers' instructions and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that SPS eyewash stations are checked weekly and the checks documented and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all CS inspectors complete the CS Drug-Diversion Inspection Certification prior to beginning CS inspections.
Closure Date:
7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected, that inspectors are sufficiently rotated in inspection assignments, and that inspections are randomly scheduled with no distinguishable patterns and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that a physical count of 10 line items for all unit and clinic areas during the 2nd and 3rd month of each quarter is consistently completed and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that pharmacy emergency cache inspections include monthly verification of seals and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that CS inspectors and the Chief of Pharmacy or designee consistently complete monthly inspections of the inpatient and outpatient pharmacies and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that acute care staff perform and document a patient skin inspection and risk scale upon transfer, upon change in condition, and at discharge and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, risk scale score, and date pressure ulcer acquired for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that acute care staff perform and document daily skin inspections, daily risk scales, and daily monitoring for a change in condition for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that acute care staff perform and document daily monitoring for a change in condition for all hospitalized patients identified as not being at risk for pressure ulcers and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that compliance be monitored.
Closure Date:
16 We recommended that the facility establish staff pressure ulcer education requirements and that designated employees receive training on how to administer the pressure ulcer risk scale and how to accurately document findings and that compliance be monitored.
Closure Date:
17 We recommended that each unit-based expert panel and the facility expert panel complete annual staffing plan reassessments.
Closure Date:
18 We recommended that all members of the unit-based and facility expert panels receive the required training prior to an annual staffing plan reassessment.
Closure Date:
19 We recommended that processes be strengthened to ensure that contractor tuberculosis risk assessments are conducted prior to construction project initiation.
Closure Date:
20 We recommended that processes be strengthened to ensure that designated employees receive ongoing construction safety training and that compliance be monitored.
Closure Date:
21 We recommended that processes be strengthened to ensure that all designated employees complete respirator fit testing and that compliance be monitored.
Closure Date:
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11259