OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Oversight Reports

Inspection of the VA Regional Office St. Louis, Missouri

9/7/2017 | 17-02150-340 | Summary | Report | 8 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director implement a plan to provide refresher training on Special Monthly Compensation and monitor the effectiveness of that training.

No. 2   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director implement a plan to ensure Special Monthly Compensation rating decisions receive a second signature review by a designated subject matter expert for processing.

No. 3   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director implement a training plan, conducted by qualified staff, on the proper processing of rating reductions, and monitor the effectiveness of that training.

No. 4   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director implement a plan to ensure rating reduction cases are processed at the end of the due process time period to minimize overpayments.

No. 5   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director implement a plan to monitor the effectiveness of recent training for claims establishment.

No. 6   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.

No. 7   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director implement a training plan on how to properly process special controlled correspondence, and monitor the effectiveness of that training.

No. 8   to Veterans Benefits Administration (VBA)

We recommended the St. Louis VA Regional Office Director allocate resources to process special controlled correspondence to ensure timely responses.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Inspection of the VA Regional Office Wilmington, Delaware

9/6/2017 | 17-00970-327 | Summary | Report | 3 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Benefits Administration (VBA)

We recommended the Wilmington VA Regional Office Director implement a plan to assess the effectiveness of second-signature reviews for Special Monthly Compensation and Ancillary Benefits claims.

No. 2   to Veterans Benefits Administration (VBA)

We recommended the Wilmington VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for higher-level Special Monthly Compensation and Ancillary Benefits.

No. 3   to Veterans Benefits Administration (VBA)

We recommended that the Wilmington VA Regional Office Director implement a plan to ensure management provides a consistent quality review process which addresses all elements required when establishing claims in the electronic record and monitor the effectiveness of that plan.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that consult clinical reviews and appointment scheduling for patients are conducted in compliance with Veterans Health Administration directives and system policies.

No. 2   to Veterans Health Administration (VHA)

We recommended that Physical Medicine and Rehabilitation Services have sufficient staffing to arrange for timely consultations and appointments within the service.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility staff who schedule Physical Medicine and Rehabilitation Services patient appointments receive annual scheduling competencies to ensure understanding of the correct process for compliance with Veterans Health Administration directives and staff are monitored for compliance.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Inspection of the VA Regional Office Denver, Colorado

9/5/2017 | 17-01354-336 | Summary | Report | 4 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Benefits Administration (VBA)

We recommended the Denver VA Regional Director implement a plan to complete proposed rating reduction cases at the end of the due process period.

No. 2   to Veterans Benefits Administration (VBA)

We recommended that the Denver VA Regional Office Director implement a plan to ensure all claims processing staff receive formal training on claims establishment procedures and monitor the effectiveness of that training.

No. 3   to Veterans Benefits Administration (VBA)

We recommended the Denver VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.

No. 4   to Veterans Benefits Administration (VBA)

We recommended the Denver VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that outpatient echocardiography and stress test consult requests are scheduled and completed in accordance with Veterans Health Administration policy.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that sleep study consult requests are scheduled and completed within the timeframe required by Veterans Health Administration policy.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that patients’ cardiac diagnostic and procedure reports are signed within the timeframe specified by policy to ensure appropriate follow-up and patient care coordination.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Inspection of the VA Regional Office Philadelphia, Pennsylvania

8/24/2017 | 17-01276-300 | Summary | Report | 5 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Benefits Administration (VBA)

We recommended the Philadelphia VA Regional Office Director develop and implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.

No. 2   to Veterans Benefits Administration (VBA)

We recommended the Philadelphia VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.

No. 3   to Veterans Benefits Administration (VBA)

We recommended the Philadelphia VA Regional Office Director implement a plan to assess the effectiveness of the most recent claims establishment training.

No. 4   to Veterans Benefits Administration (VBA)

We recommended the Philadelphia VA Regional Office Director provide training on special controlled correspondence to ensure accurate and complete responses to the veteran and Congressional staff, and monitor the effectiveness of the training.

No. 5   to Veterans Benefits Administration (VBA)

We recommended the Philadelphia VA Regional Office Director improve oversight of special controlled correspondence.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers strengthen patient flow processes.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers evaluate staff's Emergency Department Integrated Software data entry and implement action plans to ensure data accuracy and timeliness.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure that the VA Maryland Health Care System managers strengthen Patient Flow Committee processes to include the establishment of patient flow goals, action target dates, and oversight of action implementation.

No. 4   to Veterans Health Administration (VHA)

We recommended that the System Director ensure that policy regarding patients boarding in the Emergency Department include all required elements.

No. 5   to Veterans Health Administration (VHA)

We recommended that the System Director strengthen Bed Management Solution utilization and processes, and monitor compliance.

No. 6   to Veterans Health Administration (VHA)

We recommended that the System Director strengthen processes to improve timeliness of bed cleaning.

No. 7   to Veterans Health Administration (VHA)

We recommended that the System Director review the impact of inpatient medicine admission capping and establish alternative plans that improve patient flow from the Emergency Department, monitor outcomes, and implement alternative plans as warranted.

No. 8   to Veterans Health Administration (VHA)

We recommended that the System Director review and address processes that contribute to delays of inpatient discharge.

No. 9   to Veterans Health Administration (VHA)

We recommended that the System Director strengthen nursing service communication processes to ensure consistent inpatient care coverage and nurses' availability for Emergency Department handoff.

No. 10   to Veterans Health Administration (VHA)

We recommended that the System Director evaluate the adequacy of Emergency Department administrative support staffing and take appropriate action.

No. 11   to Veterans Health Administration (VHA)

We recommended that the System Director improve and monitor compliance with response time requirements for after-hour computerized tomography scan services.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Inspection of the VA Regional Office Louisville, Kentucky

8/23/2017 | 17-00394-298 | Summary | Report | 5 Recommendations

Legend:   Open|   Closed

No. 1   to Veterans Benefits Administration (VBA)

We recommended the Louisville VA Regional Office Director assess the effectiveness of the most recent refresher training for higher level special monthly compensation.

No. 2   to Veterans Benefits Administration (VBA)

We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight and assess the accuracy of secondary reviews involving higher-level special monthly compensation and ancillary benefits.

No. 3   to Veterans Benefits Administration (VBA)

We recommended the Louisville VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.

No. 4   to Veterans Benefits Administration (VBA)

We recommended the Louisville VA Regional Office Director implement a plan to conduct training that emphasizes date of claim policies and accurate contention classifications, and to monitor the effectiveness of the training.

No. 5   to Veterans Benefits Administration (VBA)

We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight for newly hired staff who establish claims.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

Legend:   Open|   Closed

No. 1   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director convene an expert panel knowledgeable in the subspecialties of Pain Medicine and Addiction Medicine to review the subject provider’s opioid prescribing practices within the context of the patients whose treatment varied from guidelines as described in this report, ensure that the expert panel expand the review as necessary, and submit a report of findings to the Veterans Integrated Service Network and Facility Directors.

No. 2   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure the monitoring patients on Suboxone.

No. 3   to Veterans Health Administration (VHA)

We recommended that the Veterans Integrated Service Network Director ensure the Pain Committee strengthens processes to improve communication with the facility to ensure information is relayed timely.

No. 4   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure that providers access the Prescription Drug Monitoring Program database as required by facility policy and monitor compliance.

No. 5   to Veterans Health Administration (VHA)

We recommended that the Facility Director ensure adequate resources, such as additional staff or allotted duty time, are allocated for patient reviews for opioid therapy appropriateness.

Total Monetary Impact of All Recommendations

These recommendations have no monetary value.

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