Recommendations
2099
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-01255-242 | Review of Veterans Health Administration’s National Teleradiology Program | National Healthcare Review | ||
1 The Director, National Teleradiology Program ensures guidance in memoranda of understanding, teleradiology service agreements, and policies related to the entity responsible for the completion of National Teleradiology Program radiologist peer reviews is consistent and aligns with Veterans Health Administration requirements.
2 The Director, National Teleradiology Program reviews the barriers, to include staffing shortages, to achieving turnaround time goals and creates a plan of action to optimize results.
3 The Director, National Teleradiology Program, in cooperation with Veterans Health Administration’s National Radiology Program, explores additional options for the recruitment and retention of National Teleradiology Program radiologists.
4 The Under Secretary for Health, in cooperation with Veterans Health Administration’s National Radiology Program, reviews the tools available for the recruitment and retention of radiologists across the Veterans Health Administration and creates a plan of action to optimize filling vacant positions.
5 The Under Secretary for Health ensures all facilities with an agreement for service by the National Teleradiology Program have a contingency plan.
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| 25-00206-14 | Healthcare Facility Inspection of the VA Altoona Healthcare System in Pennsylvania | Healthcare Facility Inspection | ||
1 The Executive Director ensures each service has a service-level workflow for test result communication.
Closure Date:
2 The Executive Director reviews current practices to obtain documents from community providers and determines if leaders can standardize an approach to improve timeliness.
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| 25-00302-243 | Review of VISN 21 Clinical Resource Hub Sleep Medicine Physician Privileging | Hotline Healthcare Inspection | ||
1 The San Francisco Healthcare System Director confirms the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub sleep medicine licensed independent practitioners are privileged in accordance with policy and monitors for compliance.
2 The Sierra Pacific Veterans Integrated Service Network Director ensures Sierra Pacific Veterans Integrated Service Network leaders and San Francisco Healthcare System leaders are educated on Veterans Health Administration policies regarding actions required following licensed independent practitioners’ lapse in privileges.
3 The Sierra Pacific Veterans Integrated Service Network Director confirms the San Francisco Healthcare System and the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub leaders complete a review of clinical care rendered by physicians with lapsed privileges as required by the Veterans Health Administration directive.
4 The Under Secretary for Health ensures the Veterans Health Administration National Program Director, Sleep Medicine and the National Sleep Medicine Field Advisory Board review sleep medicine privileges and provide national guidance for sleep medicine physicians who seek other specialty privileges.
5 The San Francisco Healthcare System Director ensures that the Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub director addresses sleep medicine physicians’ concern of potential for disruptions in sleep medicine services without dual privileges and notifies sites receiving Sierra Pacific Veterans Integrated Service Network Clinical Resource Hub services if sleep medicine privilege changes will disrupt services.
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| 25-00824-227 | Audit of Funding Fee Refunds for Veterans Using Dual Entitlement on VA Joint Home Loans | Audit | ||
1 Identify all veterans using dual entitlement on VA-guaranteed joint home loans who were charged funding fees and received a retroactive disability rating that precedes their loan closing date since July 2019 when the veteran refund eligibility list was implemented, and issue required refunds.
2 Update systems to ensure eligible veterans using dual entitlement on joint VA-guaranteed home loans are identified for funding fee refunds and ensure that any system updates are tested to demonstrate that the entire population of eligible veterans is included.
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| 25-00349-10 | Review of Quality of Care for Patients Seeking Acute Mental Health Care at the Lexington VA Healthcare System in Kentucky | Hotline Healthcare Inspection | ||
1 The Lexington VA Healthcare System Director ensures emergency department, mental health, and inpatient medical and nursing staff responsible for suicide risk assessment understand the need to evaluate patients for a personally owned insulin pump and remove the insulin pump prior to inpatient admission, when necessary and monitors for compliance.
2 The Lexington VA Healthcare System Director verifies the draft insulin pump policy is finalized, and Lexington VA Healthcare System emergency department, mental health, and inpatient medical and nursing staff are educated on the policy.
3 The Lexington VA Healthcare System Director ensures leaders and staff review the Lexington VA Healthcare System policy evaluation and approval procedure.
4 The Lexington VA Healthcare System Director verifies that patients receive discharge instructions, with a follow-up care plan when discharged from the Lexington VA Healthcare System emergency department.
5 The Lexington VA Healthcare System Director ensures a review of Psychiatrist 2’s documentation in Patient 2’s electronic health record and makes certain documentation is completed according to Veteran Health Administration policy, including that entries are accurate, succinct, without extensive copy and paste, and devoid of derogatory, critical, comments, and takes action as warranted.
6 The Lexington VA Healthcare System Director confirms that the patient safety managers understand and apply Veteran Health Administration guidance to accurately use safety assessment codes when scoring a patient safety event.
7 The Lexington VA Healthcare System Director verifies that root cause analyses are completed according to Veterans Health Administration policy including interviewing individuals knowledgeable about the event.
8 The Lexington VA Healthcare System Director ensures peer representation at the Peer Review Committee for psychiatry case reviews.
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| 25-03462-12 | Management of Personally Owned Insulin Pumps for Patients at Risk for Suicide in Emergency Departments and Inpatient Units | National Healthcare Review | ||
1 The Under Secretary for Health considers specific VHA guidance related to the recognition of personally owned insulin pumps as a lethal means for patients with suicidal ideation and at risk for suicide in emergency departments and inpatient units to mitigate risk and improve patient safety.
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| 24-03416-237 | Healthcare Facility Inspection of the Minneapolis VA Health Care System in Minnesota | Healthcare Facility Inspection | ||
1 The Associate Director ensures staff make feminine hygiene products available in public women’s and unisex restrooms.
2 The Medical Center Director ensures staff implement processes to secure medications from unauthorized access.
3 Biomedical staff indicate inspection dates on all equipment.
Closure Date:
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| 25-00196-05 | Healthcare Facility Inspection of the Miami VA Healthcare System in Florida | Healthcare Facility Inspection | ||
1 The Executive Director ensures staff address environment of care deficiencies within 14 days or have an action plan, as required.
2 The Executive Director ensures staff perform preventive maintenance on medical equipment in accordance with manufacturers’ recommendations.
3 The Executive Director ensures staff evaluate the best place to store cleaning supplies, staff store them there, and leaders monitor compliance.
4 The Executive Director ensures staff remove expired medical supplies and patient food items from patient care areas.
5 The Executive Director ensures doors in patient care areas have signs to indicate what is stored inside.
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| 25-00197-236 | Healthcare Facility Inspection of the VA Tennessee Valley Healthcare System in Nashville | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff perform preventive maintenance in accordance with manufacturers’ guidelines and clearly define staff responsibilities.
Closure Date:
2 Executive leaders continue to recruit a permanent chief of biomedical engineering and implement processes to prevent repeat environment of care findings.
Closure Date:
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| 25-02447-08 | Review of Community Care Utilization, Delivery of Timely Care, and Provider Qualifications at the VA Boston Healthcare System in Massachusetts, Fiscal Year 2024 | National Healthcare Review | ||
1 The VA Boston Healthcare System Director assesses the timeliness of appointment setting for VA direct and community care referrals and ensures facility staff establish appointments within required time frames.
2 The VA Boston Healthcare System Director reviews consult management practices and ensures the proper use of consults for VA direct care referrals.
3 The VA Boston Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.
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