Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00593-181 | Healthcare Facility Inspection of the VA Central Ohio Health Care System in Columbus | Healthcare Facility Inspection | ||
1 Facility leaders implement a standardized process for service-level communication to consistently disseminate information.
Closure Date:
2 Facility leaders ensure Environmental Management Services staff keep patient areas clean and walls intact to minimize the spread of infection.
Closure Date:
3 The Medical Center Director evaluates the allocation of resources to ensure the Housing and Urban Development–Veterans Affairs Supportive Housing program meets the needs of the veterans served.
Closure Date:
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| 24-00395-179 | Inspection of Select Vet Centers in Midwest District 3 Zone 3 | Vet Center Inspection Program | ||
1 District leaders and the Kansas City Vet Center Director determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
2 District leaders and the Des Moines, Sioux City, and Kansas City Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
Closure Date:
3 District leaders and the Des Moines, Sioux City, Kansas City, and Rapid City Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
4 District leaders and the Kansas City Vet Center Director determine reasons for noncompliance with monthly automated external defibrillator inspections, ensure completion, and monitor compliance.
5 District leaders and the Kansas City and Rapid City Vet Center Directors determine reasons for noncompliance with having an emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
Closure Date:
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| 24-00393-180 | Inspection of Select Vet Centers in Midwest District 3 Zone 1 | Vet Center Inspection Program | ||
1 District leaders and the Detroit, Escanaba, and Cincinnati Vet Center Directors collaborate with the supporting VA medical facility to determine reasons for noncompliance with staff participation on the mental health executive council, take action as indicated, and monitor compliance.
2 District leaders and the Fort Wayne, Escanaba, and Cincinnati Vet Center Directors 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.
3 District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with employees completing select trainings in the required time frame, ensure completion, and monitor compliance.
4 District leaders and the Fort Wayne, Detroit, Escanaba, and Cincinnati Vet Center Directors determine reasons for noncompliance with completion of an outreach plan with all required strategic components, ensure completion, and monitor compliance.
5 District leaders and the Escanaba Vet Center Director determine reasons for noncompliance with annual fire or safety inspections, ensure completion, and monitor compliance.
6 District leaders and the Fort Wayne, Detroit, and Escanaba Vet Center Directors determine reasons for noncompliance with having an annual risk and vulnerability assessment completed by VA police or local law enforcement, ensure completion, and monitor compliance.
7 District leaders and the Cincinnati Vet Center Director determine reasons for noncompliance with annual automated external defibrillator servicing by VA medical center biomedical engineering, ensure completion, and monitor compliance.
8 District leaders and the Detroit and Escanaba Vet Center Directors determine reasons for noncompliance with having a current emergency and crisis plan that includes required components, ensure completion, and monitor compliance.
9 The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to inconsistencies in frequency for risk and vulnerability assessments and updates the administrative site visit protocol as indicated.
10 The Readjustment Counseling Service Chief Officer reviews the administrative site visit protocol and Veterans Health Administration requirements related to automated external defibrillator annual servicing and updates the administrative site visit protocol as indicated.
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| 24-02930-175 | Deficiencies in Care at the Batavia Community Living Center Contributed to a Resident’s Death at the VA Western New York Healthcare System in Buffalo | Hotline Healthcare Inspection | ||
1 The VA Western New York Health Care System Executive Director ensures that community living center staff complete behavioral notes and conduct behavioral rounds, consistent with system policies regarding behavioral health and administration of antipsychotic medications, monitors for compliance, and takes action as indicated.
2 The VA Western New York Health Care System Executive Director evaluates community living center nursing staff compliance with system policies regarding the administration of medications, and nursing documentation related to medication refusals, medical provider notification, and residents’ nutritional intake, and takes action as required.
3 The VA Western New York Health Care System Executive Director reviews the system policy regarding the use of antipsychotic medications in the community living center and considers aligning system policy with Veterans Health Administration’s dementia system of care recommendation to document risk-benefit discussions for all residents receiving pharmacological interventions for dementia-related behaviors.
4 The VA Western New York Health Care System Executive Director makes certain community living center staff comply with the system policy on fingerstick blood sugar testing, including documenting results and notification to the resident’s provider, and monitors compliance, taking action as indicated.
5 The VA Western New York Health Care System Executive Director reviews Batavia community living center laboratory processes and takes action as necessary to ensure timely completion of orders.
6 The VA Western New York Health Care System Executive Director ensures community living center staff enter joint patient safety reports and disclosures, as Veterans Health Administration guides and requires, and in support of high reliability organization principles, and monitors compliance.
7 The VA Western New York Health Care System Executive Director makes certain the community living center quality assurance performance improvement procedures adhere to Veterans Health Administration requirements, including the use of data to track effectiveness of quality assurance activities, and supports improvement in community living center nursing care.
8 The VA Western New York Health Care System Executive Director ensures completion of the chief geriatric physician’s focused professional practice evaluation for cause per Veterans Health Administration requirements.
9 The VA Western New York Health Care System Executive Director evaluates community living center medical provider staffing to ensure staffing meets patient care needs and takes action as necessary, including continued recruitment to fill vacancies.
10 The VA Western New York Health Care System Executive Director ensures review of education plans, education needs assessments, and completion of a system dementia education plan as well as initial and ongoing Staff Training in Assisted Living Residences-VA training, as expected, for all community living center nursing staff, and takes action as indicated.
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| 24-02059-177 | Failures Related to the Care and Discharge of a Patient and Leaders’ Response at the VA New Mexico Healthcare System in Albuquerque | Hotline Healthcare Inspection | ||
1 The VA New Mexico Healthcare System Director ensures that social work staff are knowledgeable that 10-10EZR forms can be completed at any time to correct a patient’s financial information and documents are not required to verify financial information.
2 The VA New Mexico Healthcare System Director reviews the ineffective communication, collaboration, and utilization of available sources of information by social work staff and the enrollment and eligibility supervisor and ensures the ongoing assessment of barriers that could affect patients’ care.
3 The VA New Mexico Healthcare System Director identifies why postsurgical follow-up care was not coordinated for the patient and takes action as warranted.
4 The VA New Mexico Healthcare System Director educates emergency department providers on the expectation for identifying the eligibility of each patient who requires admission and the need to obtain Chief of Staff approval if an ineligible patient necessitates care at the facility.
5 The VA New Mexico Healthcare System Director ensures that inpatient providers are aware of the process to obtain Chief of Staff approval for an ineligible patient to continue care at the facility when clinically indicated.
6 The VA New Mexico Healthcare System Director reviews the process for note retractions and ensures providers and document specialists are trained on the process.
7 The VA New Mexico Healthcare System Director ensures that inpatient social workers, providers, transfer coordinators, and nurses are aware that ineligible patients can be transferred from the facility and provides education related to the processes required for approval and facilitation of the transfer.
8 The VA New Mexico Healthcare System Director monitors compliance with the requirement that discharge paperwork is provided to each patient who is discharged.
9 The VA New Mexico Healthcare System Director ensures that providers communicate relevant information to community healthcare providers as needed to ensure continuity of care.
10 The VA New Mexico Healthcare System Director evaluates that staff (inpatient social workers, providers, transfer coordinators, nurses, and the nursing officer of the day) are aware that ineligible patients can be transported from the facility and provides education related to the processes required for approval and facilitation of the transport.
11 The VA New Mexico Healthcare System Director educates staff on steps to take if attempts to escalate concerns to their supervisors are not adequately addressed.
12 The VA New Mexico Healthcare System Director reviews the facility’s root cause analysis process, ensures that staff directly involved in an adverse event do not participate in root cause analysis of an event, and considers if another root cause analysis should be completed on this event.
13 The VA New Mexico Healthcare System Director makes certain that leaders are aware when assigned as responsible for root cause analysis action items and adhere to action plan due dates.
14 The VA New Mexico Healthcare System Director takes action to ensure that leaders understand and effectively utilize high reliability organization principles noted in this report to identify and correct deficiencies.
15 The VA New Mexico Healthcare System Director monitors the podiatry residency program for compliance with VHA Directive 1400.01 postgraduate year 1 resident supervision requirements.
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| 24-01429-145 | Implementation of a Military Sexual Trauma Operations Center Resulted in Minimal Change Despite Planned Intent to Improve Claims-Processing Accuracy | Review | ||
1 Develop and implement a method to identify and report separate quality statistics for the Military Sexual Trauma Operations Center.
2 Update the existing two-signature review process for claims processors and designated reviewers to include an increased focus on military sexual trauma denials.
3 Develop and implement a process to assess designated reviewers’ competency in processing denied military sexual trauma claims and monitor effectiveness.
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| 24-00825-176 | Care in the Community Inspection of Medical Facilities in VISN 4: VA Healthcare | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care leaders complete the staffing tool reassessment every 90 days.
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter patient safety events into the Joint Patient Safety Reporting system.
4 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures staff import all community care documents into patients’ electronic health records within five business days of receipt.
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain community providers’ medical documents prior to administratively closing consults.
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documents within 90 days of the appointment following administrative closure of non-low-risk consults.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note in the electronic health record to document all care coordination activities for consults with an assigned level of care coordination other than basic.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their scheduled community care appointments and received care.
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in the electronic health record when they receive urgent care documents.
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| 24-00824-174 | Care in the Community Inspection of Medical Facilities in VISN 10: VA Healthcare System Serving Ohio, Indiana, and Michigan | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, confirms community care clinical staffing needs and takes action as necessary.
Closure Date:
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.
4 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures staff import all community care documents into patients’ electronic health records within five business days of receipt.
Closure Date:
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain community providers’ medical documents prior to administratively closing consults.
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two attempts to obtain community providers’ medical documents within 90 days of the appointment following administrative closure of non-low-risk consults.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate supporting medical documents with requests for additional services forms into patients’ electronic health records.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm community providers signed the requests for additional services forms.
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval letters to community providers for requests for additional services.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval letters to patients for requests for additional services.
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care coordination other than basic.
14 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their scheduled community care appointments and received care.
15 Veterans Health Administration creates a process for facility staff notification of patients’ urgent care visits in the community.
16 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in electronic health records when they receive urgent care documents.
Closure Date:
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| 24-02690-167 | Deficiencies in Crisis Management of a Client, Crisis Reporting, and Documentation Practices at the Everett Vet Center in Washington | Hotline Healthcare Inspection | ||
1 The District 5 Director conducts a full review of care provided to the client by the Everett Vet Center Director and counselor, consults with Human Resources and General Counsel Offices, and takes action as needed.
2 The District 5 Director ensures vet center leaders and staff are knowledgeable about applicable state laws pertaining to duty to warn.
3 The District 5 Director makes certain that the Everett Vet Center Director and staff adhere to requirements for consultation with support facility external consultants and suicide prevention coordinators when indicated, and monitors compliance.
4 The Chief Officer, Readjustment Counseling Service provides written guidance to clarify crisis reporting criteria and monitoring responsibilities.
5 The Chief Officer, Readjustment Counseling Service establishes written policy that clarifies clinical record documentation requirements regarding entry dates; non-visit progress note completion time frames; and progress note deletion and addition, and monitors compliance.
6 The Chief Officer, Readjustment Counseling Service establishes written guidance regarding time requirements for the completion of risk assessment documentation in clients’ clinical records.
7 The District 5 Director ensures readjustment counselors’ compliance with updating and reviewing safety plans as required by Readjustment Counseling Service policy.
8 The Chief Officer, Readjustment Counseling Service ensures that vet center directors are issued the correct position description and are performing duties within the identified scope of work.
9 The District 5 Director conducts a review of the care provided to complex clients by the Everett Vet Center Director since March 2021 and addresses identified clinical needs.
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| 24-02031-171 | Care in the Community Deficiencies and Ineffective VISN Oversight at the VA Maryland Health Care System in Baltimore | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health assesses the feasibility of the 7-day appointment scheduling requirement for Care in the Community consults and considers stratifying the time frame requirement according to risk.
2 The VA Maryland Health Care System Director develops and implements an education plan to address incomplete Care in the Community consult submissions and monitors efficacy of the plan.
3 The VA Maryland Health Care System Director implements Care in the Community consult management process improvements, focusing on consult completion.
4 The Veterans Integrated Service Network Director assists system leaders with completing corrective actions to improve Care in the Community performance.
5 The VA Maryland Health Care System Director ensures system Care in the Community staff create and use care coordination plan notes for documenting all care coordination activities for consults with an assigned level of care other than basic and monitors for compliance.
6 The VA Maryland Health Care System Director ensures full implementation of Veterans Health Administration’s enhanced Referral Coordination Initiative as required and monitors for compliance.
7 The VA Maryland Health Care System Director ensures Care in the Community Patient Advocate Tracking System data is analyzed for use in service-level quality and process improvement and monitors for compliance.
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14917