VAOIG-21-00942-16.pdf

..."Appendix F: Management Comments,
Director, Eastern Oklahoma VA Health Care System
Department of Veterans Affairs Memorandum
Date: November 12, 2021
From: Director, Eastern Oklahoma VA Health Care System (623/00)
Subj: Draft Report, Financial Efficiency Review of the Eastern Oklahoma VA Health Care System (2021-
00942-AE-0034)
To: Assistant Inspector General for Audits and Evaluations (52)
1.I have read and concur with the findings and recommendations in the OIG Report entitled, Draft Report,
Financial Efficiency Review of the Eastern Oklahoma VA Health Care System (2021-00942-AE-0034).
2.My response to each report recommendation can be found in the attached document.
3.If there are any questions regarding the responses to the recommendations or any additional
information is required, please contact the Chief of Quality, Safety and Value.
(Original signed by)
Mark E. Morgan, MHA FACHE

Attachments (1)
Financial Efficiency Review of the Eastern Oklahoma VA Health Care System
VA OIG 21-00942-16 | Page 34 | December 15, 2021
Attachment
Recommendation 1
Ensure finance office staff are made aware of policy requirements and reviews are conducted on all open
obligations as required by VA Financial Policies and Procedures, vol. 2, chap. 5, “Obligations Policy”
January 2018.
Healthcare system concurred.
Target date for completion: June 30, 2022
Healthcare system response: All staff responsible for open obligations oversite will demonstrate
knowledge of VHA VA Financial Policies and Procedures, vol 2, chap 5, “Obligations Policy”, January
2018, updated in August 2018, by reading the policy and attesting by signature they have read and
understand said policy. The Chief of Fiscal Services will perform monthly audits of open obligations to
ensure validity, accurate end dates. And those which exceed 90 days have been validated to ensure
obligations are still accurate and have legitimate length of inactivity. The audit will continue until two
consecutive quarters have a compliance rate of at least 90%. The denominator will be the number of
open obligations and the numerator will be the number open obligations with activity at least every 90
days.
Recommendation 2 – VISN 19
Develop checks on the successful completion of quarterly audits of the purchase card program as
required by the Veterans Health Administration’s standard operating procedure, “Internal Audits—
Purchase Cards and Convenience Checks.”
Healthcare system concurred.
Target date for completion: July 31, 2021
Healthcare system response: The quarterly audit memo dates for FY20 were corrected and it was verified
that audits were completed in accordance with VHA Audit SOP. The SOP was provided to card holders
and approving officials as well as the facility director. The dates are now being reflected correctly to
ensure timely completion and reporting of audits. Request closure.
Recommendation 3
Establish controls to confirm approving officials and purchase cardholders review their purchases and
make sure contracting is used when it is in the best interest of the government.
Healthcare system concurred.
Target date for completion: June 30, 2022
Healthcare system response: Service Chiefs and local leadership will increase utilization of local
AUS (Acquisition Utilization Specialist) to assist in timely annual procurement planning and guidance on
the proper acquisition vehicles (contracts or Government Purchase Card) Approving Officials have the
responsibility to approve all purchase card transactions prior to purchase. Approving Official must
increase their awareness of reoccurring requirements and assess the needs going forward. Stakeholders
will increase their use of various resources for guidance on proper use and source selection, to include
NCO19 purchase card program coordinators, local AUS and contracting points of contacts.
Financial Efficiency Review of the Eastern Oklahoma VA Health Care System
VA OIG 21-00942-16 | Page 35 | December 15, 2021
Recommendation 4
Ensure cardholders comply with record retention requirements as stated in VA’s Financial Policy, vol. XVI,
“Charge Card Program.”
Healthcare system concurred.
Target date for completion: November 19, 2021
Healthcare system response: All Eastern Oklahoma Veterans Administration Health Care System
employees with Government Purchase Cards complete annual TMS training for use of said card. All
employees with Government Purchase Cards have read VA Financial Policy, vol. XVI, chap. 1A,
“Administrative Actions for Government Purchase Cards,” June 14, 2018 and attested their understanding
by signing of referenced policy.
Recommendation 5
Develop measures to confirm completed VA Form 0242 submissions are accurate and
Healthcare system concurred.
Target date for completion: October 31, 2021
Healthcare system response: 0242’s are updated as soon as the stakeholders notify the purchase card
program of changes to single limits, changes in card holders names, Administrative Officers (AO) and
Associate Administrative Officer’s (AAO). In response to the findings, 0242s dated prior to the purchase in
question were provided which is in line with other audit methods, subsequently update 0242’s was
provided to the auditor reflecting the changes in AO’s and AAO’s contained in the Charge Card Portal
(CCP). Regarding the single purchase limits discrepancies on the original submitted 0242’s the below
attachments outlined allowances regarding 10K and Covid 20K limits. A quarterly review of 0242’s will
continue to be conducted. All limits have been updated in the new Charge Card Portal (CCP). Request
Closure
Recommendation 6
Develop formalized processes for achieving identified efficiency targets and use available pharmacy data
to make business decisions.
Healthcare system concurred.
Target date for completion: June 30, 2022
Healthcare system response Chief of Pharmacy contacted OPES October 5, 2021 and requested review
Eastern Oklahoma Veterans Administration Health Care System data and verify efficiency data and offer
opportunities for improvement. OPES projected December 1, 2021 as estimated date in which Eastern
Oklahoma Veterans Administration Health Care System would receive their final report. September 28,
2021, Chief of Pharmacy met with Chief of Primary Care, and both Associate Chiefs of Primary care to
improve prescribing practices by providing VIONE education to new providers and reeducate all current
providers.
Recommendation 7
Develop and implement a plan to increase inventory turnover closer to the VHA-recommended level.
Healthcare system concurred.
Target date for completion: January 31, 2022
Financial Efficiency Review of the Eastern Oklahoma VA Health Care System
VA OIG 21-00942-16 | Page 36 | December 15, 2021
Healthcare system response: In FY 2020, the healthcare system reported an inventory turn of 5.6
compared to the VHA average of 10.6 and VHA’s recommended level of 12, as established by the
national Pharmacy Benefits Management program office. In January 2021, Eastern Oklahoma Veterans
Administration Health Care System conducted the annual inventory and reflected an inventory turn rate of
16. The next inventory is scheduled for January 2022.
Recommendation 8
Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items
in compliance with VHA policy.
Healthcare system concurred.
Target date for completion: January 31, 2022
Healthcare system response: All noncontrolled audits were completed as required by VHA policy.
On January 8, 2021 All Eastern Oklahoma Veterans Administration Health Care System exceeded five
percent due to a noncontrolled drug being expired and returned via reverse distributer. Subsequent
noncontrolled audits demonstrate less than a five percent variance with April 9, 2021 reflecting a 0.1
percent variance, July 8, 2021 0.6 percent variance, October 8, 2021 with a variance of 0.2 percent.
Recommendation 9
Establish measures to improve compliance with the nonformulary request process.
Healthcare system concurred.
Target date for completion: January 31, 2022
Healthcare system response: All nonformulary “Quick Orders” were disabled on September 1, 2020. All
nonformulary drug requests have since been facilitated by the requesting provider entering a
nonformulary consult which is then reviewed by pharmacy staff for appropriateness. An appeals process
was voted on during the July 28, 2021 Pharmacy and Therapeutics Committee meeting, approved, and
implemented for nonformulary denials."...