Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-02863-199 | Alleged Split Purchases at the VA St. Louis Health Care System | Audit | ||
1 The Health Care System Director submits ratification requests to the Veterans Health Administration’s Head of Contracting Activity for the split purchases and the purchases that exceeded the micropurchase threshold identified in the OIG report for calendar years 2014 and 2015.
Closure Date:
2 The Health Care System Director provides additional training for purchase cardholders and approving officials focused on avoiding split purchases and complying with micropurchase thresholds.
Closure Date:
3 The Health Care System Director establishes a rigorous monitoring mechanism to ensure management controls are in place and working to identify and prevent improper purchase card transactions.
Closure Date:
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| 17-04966-201 | Unwarranted Medical Reexaminations for Disability Benefits | Audit | ||
1 The Under Secretary for Benefits establishes internal controls sufficient to ensure that a reexamination is necessary prior to employees ordering it, and modifies VBA procedures as appropriate to reflect these improved business processes.
Closure Date:
2 The Under Secretary for Benefits takes steps to prioritize the design and implementation of system automation reasonably designed to minimize unwarranted reexaminations.
Closure Date:
3 The Under Secretary for Benefits enhances VBA’s quality assurance reviews to evaluate whether employees correctly requested reexaminations and categorize unwarranted reexaminations as errors.
Closure Date:
4 The Under Secretary for Benefits conducts a special focused quality improvement review of cases with unwarranted reexaminations to develop data sufficient to understand and redress the causes of any avoidable errors.
Closure Date:
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| 16-03137-208 | Supervision and Care of a Residential Treatment Program Patient at a Veterans Integrated Service Network 10 Medical Facility | Hotline Healthcare Inspection | ||
1 The Facility Director ensures that Facility managers coordinate and implement uniform Program policies and procedures relating to supervision of patients, and that Facility staff consistently follow those policies and procedures.
Closure Date:
2 The Facility Director ensures that the Mental Health Treatment Coordinator and interdisciplinary team develop and document the interdisciplinary treatment plan, as required by Veterans Health Administration and Facility policy.
Closure Date:
3 The Facility Director ensures that the Program offers patient treatment, daily, as required by Veterans Health Administration.
Closure Date:
4 The Facility Director ensures that Program managers regularly evaluate restrictions to patient privileges and methods to reinstate restricted or lost patient privileges, as required by Veterans Health Administration.
Closure Date:
5 The Facility Director ensures that staff document Program patient care in the electronic health record within Veterans Health Administration and Facility requirements and timeframes.
Closure Date:
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| 18-00616-212 | Comprehensive Healthcare Inspection Program Review of the VA San Diego Healthcare System | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Ongoing Professional Practice Evaluations include service-specific performance data and monitors compliance.
Closure Date:
2 The Associate Director and Assistant Director ensure required team members consistently participate on environment of care rounds and monitor team members’ compliance.
Closure Date:
3 The Assistant Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
4 The Facility Director ensures that controlled substance inspectors perform reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock and monitors compliance.
Closure Date:
5 The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors nurses’ compliance.
Closure Date:
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| 17-05432-217 | Delays in Urological Care and Alleged Lack of Non-VA Care Funding at the Beckley VA Medical Center, West Virginia | Hotline Healthcare Inspection | ||
1 The Beckley VA Medical Center Director reviews consult management practices and ensuresconsult timeliness.
Closure Date:
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| 16-05323-200 | Alleged Inappropriate Controlled Substance Prescribing Practices at a Veterans Integrated Service Network 20 Medical Facility | Hotline Healthcare Inspection | ||
1 Veterans Integrated Service Network 20 Director conducts a management review of the care of the patient who is the subject of this report, and confers with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action.
Closure Date:
2 The Facility Director implements a systematic approach to review prescribing of controlled substances to individuals at high-risk for substance abuse or misuse.
Closure Date:
3 The Facility Director strengthens processes that foster interdisciplinary collaboration for the management of patients with complex clinical pain and allows referrals from all Facility staff.
Closure Date:
4 The Facility Director ensures that policy and practice is consistent with Veterans Health Administration Directive 1005, Informed Consent for Long-term Opioid Therapy for Pain.
5 The Facility Director ensures provider accountability for compliance with Veterans Health Administration and Facility controlled substance policies, including opioid informed consent policies.
Closure Date:
6 The Facility Director strengthens the Facility Board that is responsible for controlled substances safety, including clarification of roles, responsibilities, and authority; and the development of clearly written definitions and entry criteria for Category II patient record flags in accordance with Veterans Health Administration policy.
Closure Date:
7 The Facility Director maintains full compliance with the Veterans Health Administration’s peer review directive, including but not limited to the selection of impartial reviewers and removing the service chief level review from the Facility peer review process.
8 The Facility Director performs a focused professional practice evaluation on primary care provider 1’s opioid prescribing practices in high-risk patients.
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| 16-00284-214 | Alleged Inappropriate Anesthesia Practices at the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania | Hotline Healthcare Inspection | ||
1 The James E. Van Zandt VA Medical Center Director ensures that the James E. Van Zandt VA Medical Center’s anesthesia needs and services are evaluated and align with Veterans Health Administration and James E. Van Zandt VA Medical Center policies.
Closure Date:
2 The James E. Van Zandt VA Medical Center Director ensures that service chief provider oversight includes facility-specific privileges and provider-specific Ongoing Professional Practice Evaluations.
Closure Date:
3 The James E. Van Zandt VA Medical Center Director ensures that James E. Van Zandt VA Medical Center leaders consult with the Office of Chief Counsel to determine if the anesthesiologist should be reported to the National Practitioner Data Bank and the State Licensing Board for administrating medications inconsistent with the Food and Drug Administration approved manufacturer’s instructions.
Closure Date:
4 The James E. Van Zandt VA Medical Center Director ensures that the Patient Advocate enters all patient complaints into the Patient Advocate Tracking Systems database; documents issue descriptions and actions taken; and tracks all complaints to resolution.
Closure Date:
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| 17-04354-187 | Patient Overdose Death in a Residential Rehabilitation Treatment Program at a VISN 1 Medical Facility | Hotline Healthcare Inspection | ||
1 The VISN 1 Medical Facility Director ensures that staff receive education about the process for initiating Medication Assisted Therapy for patients enrolled in the Program.
Closure Date:
2 The VISN 1 Medical Facility Director ensures that a standard operating procedure is issued to effectively track patients enrolled in the Program who fail to show for appointments at off-site substance abuse day programs.
Closure Date:
3 The VISN 1 Medical Facility Director ensures that all appropriate staff receive training regarding the standard operating procedure for tracking patients enrolled in the Program who fail to show for appointments in at off-site substance abuse day programs.
Closure Date:
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| 16-02247-165 | VA Southern Nevada Healthcare System's Alleged Unnecessary Use of Outside Vendors to Purchase Prosthetics | Audit | ||
1 The Acting Veterans Integrated Service Network 21 Director ensures the Director of the VA Southern Nevada Healthcare System develops and implements effective processes such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetics Laboratory operates in a manner that maximizes its personnel and on hand inventory to provide veterans with timely and cost effective fitting services for compression garments and orthotic shoes.
2 The Acting Veterans Integrated Service Network 22 Director ensures the VA San Diego Healthcare System Director takes steps such as using National Prosthetics Patient Database workload data reports to monitor and ensure the Prosthetic Service operates in a manner that maximizes its resources to provide veterans with timely and cost effective fitting services compression garments and orthotic shoes.
3 The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements effective processes to monitor purchasing employees’ usage of all non item Healthcare Common Procedure Coding System codes to ensure the proper utilization of these codes.
4 The Acting Veterans Integrated Service Network 21 Director ensures the VA Southern Nevada Healthcare System Director develops and implements a process to examine the 4,530 consults closed, but not cloned, by purchasing employees using the NR018 code from October 2014 through May 2016 and take necessary action to ensure veterans received their prescribed prosthetic or orthotic item(s).
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| 17-05399-194 | Comprehensive Healthcare Inspection Program Review of the VA Hudson Valley Health Care System, Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Facility clinical managers consistently initiate Focused Professional Practice Evaluations and that they are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
2 The Associate Director ensures all required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
3 The Associate Director ensures damaged or soiled furnishings and equipment in patient care areas are sanitized, repaired, or removed from service and monitors compliance.
Closure Date:
4 The Associate Director ensures that shower soap dispensers in the acute Mental Health Unit are replaced as required by the Mental Health Environment of Care Checklist and monitors compliance.
Closure Date:
5 The Facility Director ensures that all Controlled Substance Inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
Closure Date:
6 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
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14957