Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 18-00609-185 | Comprehensive Healthcare Inspection Program Review of the Memphis VA Medical Center | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures Facility staff enter all patient incidents into WebSPOT or the VHA Patient Safety Information System and monitors compliance.
Closure Date:
2 The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired Licensed Independent Providers and monitors compliance
Closure Date:
3 The Chief of Staff ensures that service chiefs include review of relevant data in Ongoing Professional Practice Evaluations to determine continuation of current privileging for Licensed Independent Providers and monitors compliance.
Closure Date:
4 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
5 The Associate Director ensures Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
Closure Date:
6 The Associate Director ensures that bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
Closure Date:
7 The Associate Director ensures clinical staff remove expired medications from patient care areas and monitors compliance.
Closure Date:
8 The Associate Director ensures the Facility managers maintain a safe and clean environment at the Covington North Community Based Outpatient Clinic and monitors compliance.
Closure Date:
9 The Associate Director ensures that Community Based Outpatient Clinic staff maintain clear means of egress at the Covington North Community Based Outpatient Clinic and monitors compliance.
Closure Date:
10 The Associate Director ensures that environmental management service staff maintain clean air ducts and ventilation grills in food service and storage areas and monitors compliance.
Closure Date:
11 The Facility Director ensures the Controlled Substance Coordinator completes and documents annual controlled substance inspector training and monitors compliance.
Closure Date:
12 The Chief of Staff ensures that Geriatric and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.
Closure Date:
13 The Associate Director for Patient Care Services ensures that all staff involved in managing central lines receive central line-associated bloodstream infection prevention education and monitors compliance.
Closure Date:
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| 17-02484-189 | Alleged Mismanagement of Inpatient Care at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas | Hotline Healthcare Inspection | ||
1 The System Director ensures provider privileges are facility-specific as required by Veterans Health Administration Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
Closure Date:
2 The System Director ensures the System’s Bylaws and Rules of the Medical Staff are updated to reflect compatibility and compliance with 38 CFR 17.415, Full Practice Authority for Advance Practice Registered Nurses.
Closure Date:
3 The System Director ensures the Facility meets the requirements for physician staffing for inpatient coverage, pre-operative risk and anesthesia assessments, and anesthesia services in-house coverage as required by Veterans Health Administration Directive 2010-018, Facility Infrastructure Requirements to Perform Standard, Intermediate, or Complex Surgical Procedures, May 6, 2010.
Closure Date:
4 The System Director reviews the timeliness of specialty care consults and ensures that specialty consults are provided timely as required by Veterans Health Administration policy, including the use of service/care coordination agreements as necessary to define time frames.
Closure Date:
5 The System Director ensures the Facility provides a list to the Emergency Department and inpatient staff of appropriate on-call social work and mental health staff, as well as specialty physicians, including radiologists, as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
Closure Date:
6 The System Director ensures the Facility provides and monitors the availability and timely response of specialty consultants and ultrasound services in the Emergency Department as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
Closure Date:
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| 18-01693-196 | OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages FY 2018 | National Healthcare Review | ||
1 The Under Secretary for Health refines and formalizes VHA’s position categorization of individuals (clinical and nonclinical) who are necessary to VHA’s mission of delivering health care by looking at various dimensions of each occupation, including staff skill set and function, enabling identification of positions based on the specific role a person would fill.
Closure Date:
2 The Under Secretary for Health ensures the consistent implementation and use of the position categorization approach across all facilities.
Closure Date:
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| 18-00611-180 | Comprehensive Healthcare Inspection Program Review of the Phoenix VA Health Care System, Phoenix, Arizona | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director 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 all patient incidents are entered into WebSPOT and monitors compliance.
Closure Date:
3 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
Closure Date:
4 The Deputy Director and Associate Director ensure personal protective equipment is readily accessible and monitor compliance.
Closure Date:
5 The Associate Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
6 The Associate Director requires Nutrition and Food Service managers ensure garbage receptacles are stored separately from food preparation areas and properly covered with tight-fitting lids and monitors managers’ compliance.
Closure Date:
7 The Associate Director requires Nutrition and Food Services managers ensure all food items are properly labeled with expiration dates, as appropriate, and monitors managers’ compliance.
Closure Date:
8 The Associate Director requires Nutrition and Food Services managers ensure temperature monitoring occurs in the dry food storage area and monitors managers’ compliance.
Closure Date:
9 The Facility Director ensures that Controlled Substances Inspectors complete routine monthly controlled substances inspections and monitors compliance.
Closure Date:
10 The Facility Director ensures that controlled substances inspections are randomly performed to ensure the element of surprise and monitors compliance.
Closure Date:
11 The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
Closure Date:
12 The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
13 The Chief of Staff ensures that geriatric evaluation providers complete a medical evaluation of patients admitted to the program and monitors providers’ compliance.
Closure Date:
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| 16-02940-183 | Colorectal Cancer Screening, Timely Colonoscopies, and Physician Coverage in the Intensive Care Unit at the James H. Quillen VA Medical Center, Mountain Home, Tennessee | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 9 Director ensures that clinical reviews are completed on the patients discussed in this report to determine whether delays adversely affected patients’ clinical care, notifies patients of lapses in care as needed, and/or takes other action as appropriate.
Closure Date:
2 The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track and recall patients who require surveillance colonoscopies.
Closure Date:
3 The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track patients for whom a diagnostic colonoscopy after a positive fecal immunochemical test is indicated as required by Veterans Health Administration and James H. Quillen VA Medical Center policy.
Closure Date:
4 The James H. Quillen VA Medical Center Director improves efforts to ensure non-VA colonoscopy reports are available for viewing in patients’ VA electronic health records.
Closure Date:
5 The James H. Quillen VA Medical Center Director ensures that processes are in place to monitor providers’ compliance with Veterans Health Administration Colorectal Cancer Screening policy including the referral of the patient for a diagnostic colonoscopy after a positive fecal immunochemical test rather than a repeat fecal immunochemical test.
Closure Date:
6 The James H. Quillen VA Medical Center Director takes action to identify patients who submitted fecal immunochemical test kits that could not be processed and notifies these patients of a need to re-submit fecal immunochemical test specimens.
Closure Date:
7 The James H. Quillen VA Medical Center Director ensures that processes are strengthened to track and monitor the distribution of fecal immunochemical test kits to patients.
Closure Date:
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| 17-05398-172 | Comprehensive Healthcare Inspection Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures all patient incidents are entered into the VHA Patient Safety Information System and monitors compliance.
Closure Date:
2 The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
Closure Date:
3 The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
4 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
5 The Associate Director ensures bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
Closure Date:
6 The Director ensures that the Alternate Control Substance Coordinator’s position description or functional statement includes an addendum for the Control Substance Coordinator’s duties and monitors compliance.
Closure Date:
7 The 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:
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15039