Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-05400-246 | Comprehensive Healthcare Inspection Program Review of the Tomah VA Medical Center, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
2 The Facility Director ensures that reconciliation of controlled substance returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Closure Date:
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| 17-04156-234 | Misuse of Time and Resources within the Veterans Engineering Resource Center in Indianapolis, Indiana | Investigative | ||
1 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 1.
Closure Date:
2 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 2.
Closure Date:
3 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 3.
Closure Date:
4 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against other OSI VERC employees identified by the OIG for misusing government time and resources associated with this endeavor.
Closure Date:
5 The Principal Deputy Under Secretary assesses the adequacy of oversight and training for OSI VERC employees regarding the appropriate use of VA time and resources and addresses any deficiencies.
Closure Date:
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| 17-02643-239 | Review of Two Mental Health Patients Who Died by Suicide, William S. Middleton Memorial Veterans Hospital Madison, Wisconsin | Hotline Healthcare Inspection | ||
1 The Facility Director expands the Facility’s Root Cause Analysis of Patient 1’s death to include interviews of all key staff by individuals who are not their supervisors; and if additional deficiencies are identified, ensures that Facility managers complete an action plan and monitor compliance.
Closure Date:
2 The Veterans Integrated Service Network Director ensures that the Facility Director consult with the Office of Chief Counsel regarding Patient 1 and Patient 2 whether an institutional disclosure is appropriate.
Closure Date:
3 The Veterans Integrated Service Network Director ensures an ethics review is completed regarding Patient 1’s participation in the research study and provision of guidance on the voluntary participation of patients under court treatment mandates.
Closure Date:
4 The Facility Director strengthens processes to ensure that timely notification to county monitoring agencies occurs in cases of court Settlement Agreement violations.
Closure Date:
5 The Facility Director strengthens processes to ensure that Facility staff speak directly with and notify the county monitoring agency staff before an inpatient with a court Settlement Agreement is discharged.
Closure Date:
6 The Facility Director revises the mental health inpatient unit policy to include family notification with patient consent in discharge planning and ensures that Facility policy is consistent with Veterans Health Administration policy.
Closure Date:
7 The Facility Director strengthens processes to ensure that mental health clinical assessments are complete and comprehensive to include a symptom inventory and severity assessment, and monitors compliance.
Closure Date:
8 The Facility Director strengthens processes to ensure that prescribers are prescribing psychiatric medications safely including adherence to the black box warnings, and that managers complete electronic health record reviews to monitor compliance.
Closure Date:
9 The Facility Director ensures the development of a methodology for the assignment of psychiatrists as prescribers for patients with complex mental health care needs, including patients flagged as high-risk for suicide.
Closure Date:
10 The Facility Director strengthens the Ongoing Professional Practice Evaluation process to ensure that psychiatric clinical pharmacists practice within their scope of practice, and monitors compliance.
Closure Date:
11 The Facility Director ensures the development of a collaborative agreement and/or policy to address specific conditions that require oversight of psychiatric clinical pharmacists by psychiatrists in the Mental Health Service.
Closure Date:
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| 18-00617-227 | Comprehensive Healthcare Inspection Program Review of the VA Palo Alto Health Care System, California | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
Closure Date:
2 The Facility Director ensures that the Patient Safety Manager reports and documents all patient safety incidents using the Joint Patient Safety Reporting System and monitors the Patient Safety Manager’s compliance.
Closure Date:
3 The Facility Director ensures that the Patient Safety Manager submits annual reports to the leadership team for review and monitors the Patient Safety Manager’s compliance.
Closure Date:
4 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
Closure Date:
5 The Associate Director ensures the VA Police test panic alarms at the San Jose community based outpatient clinic regularly and monitors VA Police compliance.
Closure Date:
6 The Facility Director ensures that controlled substances inspectors complete monthly inspections of assigned areas and that controlled substances coordinators refrain from conducting routine inspections, and the Facility Director monitors program inspectors’ and coordinators’ compliance.
Closure Date:
7 The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Closure Date:
8 The Chief of Staff ensures that the geriatric evaluation program quality improvement data are reviewed and reported to the Quality, Safety and Value Council and monitors compliance.
Closure Date:
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| 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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15039