Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01762-88 | Comprehensive Healthcare Inspection Program Review of the VA New York Harbor Healthcare System, New York, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Medicine Service clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
Closure Date:
2 The Chief of Staff ensures quality assurance data for the anticoagulation management program are collected, analyzed, and reported quarterly at Pharmacy and Therapeutics Committee meetings and monitors compliance.
Closure Date:
3 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and refer patients prescribed direct-acting oral anticoagulants to the anticoagulation clinic and monitors clinicians’ compliance.
Closure Date:
4 The Chief of Staff requires that clinical managers include in the competency assessments of employees actively involved in the anticoagulant program knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy, and the Chief of Staff monitors clinical managers’ compliance.
Closure Date:
5 The Chief of Staff ensures inter-facility patient transfer data are analyzed and reported and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that for patients transferred out of the facility, providers consistently complete VA Forms 10-2649A and 10-2649B as required by Veterans Integrated Service Network policy and monitors providers’ compliance.
Closure Date:
7 The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information, and the Chief of Staff monitors providers’ compliance.
Closure Date:
8 The Associate Director for Facilities and Human Resources ensures the VA Police Service consistently participates on environment of care rounds and monitors compliance.
Closure Date:
9 The Associate Director for Facilities and Human Resources ensures locked mental health unit panic alarm testing documentation includes VA Police Service response time and monitors compliance.
Closure Date:
10 The Associate Director for Patient Care Services ensures that a risk assessment is completed when a locked mental health unit patient is using an electrical or mechanical hospital bed and that the room containing the bed is locked when not in use, and the Associate Director for Patient Care Services monitors compliance.
Closure Date:
11 The Facility Director ensures all members of the Interdisciplinary Safety Inspection Team complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and the Facility Director monitors compliance.
Closure Date:
12 The Chief of Staff ensures that the use of reversal agents in moderate sedation cases and the presence or absence of adverse events for all areas administering moderate sedation are reported to and trended by the Surgical, Procedural, Operative, and Therapeutic Committee and monitors compliance.
Closure Date:
13 The Chief of Staff ensures providers include a review of abnormalities of major organ systems; an airway assessment; and a review of alcohol, tobacco, or substance use or abuse in the history and physical exams and/or pre-sedation assessments and monitors providers’ compliance.
Closure Date:
14 The Chief of Staff ensures providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and monitors providers’ compliance.
Closure Date:
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| 17-01851-72 | Comprehensive Healthcare Inspection Program Review of the Central Alabama Veterans Health Care System, Montgomery, Alabama | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
Closure Date:
2 The Chief of Staff ensures that for patients transferred out of the facility, providers consistently include patient or surrogate informed consent, medical and/or behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and monitors providers’ compliance.
Closure Date:
3 The Associate Director ensures the team members responsible for comprehensive EOC rounds consistently participate and use the Comprehensive Environment of Care Assessment and Compliance Tool to document results of those rounds and monitors compliance.
Closure Date:
4 The Associate Director ensures Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that acceptable providers perform suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
6 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:
7 The Chief of Staff ensures that providers complete diagnostic evaluations for patients with positive post-traumatic stress disorder screens within 30 days of the referral and monitors providers’ compliance.
Closure Date:
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| 17-01748-82 | Comprehensive Healthcare Inspection Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures revision of local policy to specify the Quality and Performance Council as the senior-level committee responsible for key quality, safety, and value functions and co-chairs this committee.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors physician advisors’ compliance.
Closure Date:
3 The Chief of Staff ensures that anticoagulation management program quality assurance data are collected, analyzed, and reported quarterly at the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
Closure Date:
4 The Chief of Staff ensures clinical managers include anticoagulation-specific elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
Closure Date:
5 The Facility Director ensures inter-facility patient transfer data are collected, reported, and analyzed as part of the facility’s quality management program and monitors compliance.
Closure Date:
6 The Chief of Staff ensures transfer notes written by acceptable designees include a staff/attending physician countersignature and monitors acceptable designees’ compliance.
Closure Date:
7 The Associate Director ensures required team members consistently participate in environment of care rounds and monitors team members’ compliance.
Closure Date:
8 The Associate Director ensures that VA Police perform and document system-wide panic alarm testing at the Salina community based outpatient clinic and monitors compliance.
Closure Date:
9 The Chief of Staff ensures providers include an airway assessment in the history and physical examination and/or pre-sedation assessment and monitors providers’ compliance.
Closure Date:
10 The Chief of Staff ensures clinicians perform post-procedure assessments of patient pain level and monitors clinicians’ compliance.
Closure Date:
11 The Facility Director ensures the Community Nursing Home Oversight Committee continues to meet at least quarterly and monitors compliance.
Closure Date:
12 The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.
Closure Date:
13 The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
Closure Date:
14 The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor social workers’ and registered nurses’ compliance.
Closure Date:
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| 17-01742-90 | Comprehensive Healthcare Inspection Program Review of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinicians consistently provide patient education specific for newly prescribed anticoagulant medications and monitors compliance.
Closure Date:
2 The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating warfarin and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility’s capacity and monitors providers’ compliance.
Closure Date:
4 The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors providers’ compliance.
Closure Date:
5 The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees document details of the observations and deficiencies identified during monthly self-inspections, submit work orders for all items needing repair, and document corrective actions taken, and the Chief of Staff monitors employees’ compliance.
Closure Date:
6 The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees consistently conduct and document weekly contraband inspections and monitors employees’ compliance.
Closure Date:
7 The Associate Director ensures that Mental Health Residential Rehabilitation Treatment Program managers ensure that all doors not considered as the main point of entry have audible alarms and monitors managers’ compliance.
Closure Date:
8 The Chief of Staff ensures that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
9 The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and refer them and monitors providers’ compliance.
Closure Date:
10 The Chief of Staff ensures that acceptable providers complete diagnostic evaluations within 30 days for patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
11 The Chief of Staff ensures that resident physicians are assigned and granted the correct user class computer option and that clinical managers review and monitor residents’ progress notes to ensure that resident supervision documentation meets requirements, and the Chief of Staff monitors managers’ compliance.
Closure Date:
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| 17-01855-81 | Comprehensive Healthcare Inspection Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
2 The Associate Director ensures a safe respiratory environment for patients and employees in the Community Living Center units and monitors compliance.
Closure Date:
3 The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitor compliance.
Closure Date:
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| 17-01853-89 | Comprehensive Healthcare Inspection Program Review of the Alexandria VA Health Care System, Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data at least every 6 months and monitors managers’ compliance.
Closure Date:
2 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
3 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
4 The Associate Director ensures that facility managers maintain a safe and clean environment in all patient care areas and monitors the managers’ compliance.
Closure Date:
5 The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
6 The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by the medical staff and monitors compliance.
Closure Date:
7 The Chief of Staff ensures social workers and registered nurses conduct alternating, cyclical clinical visits with the required frequency and monitors their compliance.
Closure Date:
8 The Chief of Staff ensures acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
9 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:
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| 15-03059-384 | Review of Alleged Funding Security Issues of the Veterans Services Adaptable Network at VA Medical Center Orlando, FL | Audit | ||
1 The OIG recommended the executive in charge for the Office of the Under Secretary for Health, in conjunction with the executive in charge for the Office of Information and Technology, ensure that all guest internet access networks, external air gapped networks, and industrial control systems are appropriately segregated from VA networks and meet the department’s information security requirements.
Closure Date:
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| 17-01760-85 | Comprehensive Healthcare Inspection Program Review of the Huntington VA Medical Center, Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director requires the Quality, Safety, and Value Council to document meeting minutes that include evidence of the review and analysis of aggregated data, identification of opportunities for improvement, implementation of corrective actions, and evaluation of effectiveness of the actions and monitors the Quality, Safety, and Value Council’s compliance.
Closure Date:
2 The Associate Director for Patient Care Services ensures that for patients transferred out of the facility, sending nurses document transfer assessments/notes and monitors the nurses’ compliance.
Closure Date:
3 The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information and monitors providers’ 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 access to sterile supplies at the Gallipolis community based outpatient clinic is restricted and monitors compliance.
Closure Date:
6 The Associate Director ensures medical (biohazardous) waste stored for pick-up at the Gallipolis community based outpatient clinic is secured and monitors compliance.
Closure Date:
7 The Chief of Staff ensures the Community Nursing Home Oversight Committee includes a representative from acquisitions.
Closure Date:
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| 16-03405-80 | Healthcare Inspection – Primary Care Provider’s Clinical Practice Deficiencies and Security Concerns, Fort Benning VA Clinic, Fort Benning, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that the System Director evaluates the care of the subject patient (Patient 1) and consults with the Office of General Counsel for disclosure to the patient, if appropriate.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure that the System Director consults with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action(s), if any, for Primary Care Provider X and Primary Care Provider X’s supervisors.
Closure Date:
3 We recommended that the System Director ensure that providers notify patients of test values and follow up on clinical laboratory results as required.
Closure Date:
4 We recommended that the System Director ensure that providers accurately document patients’ assessment, diagnosis, and treatment information into the electronic health record.
Closure Date:
5 We recommended that the System Director ensure that consults for VHA and non-VA care are entered and completed within time frames set by Veterans Health Administration.
Closure Date:
6 We recommended that the System Director ensure that employees receive training appropriate for the assigned Workplace Behavioral Risk Assessment risk level.
Closure Date:
7 We recommended that the System Director ensure that Clinic employees are trained in emergency management procedures.
Closure Date:
8 We recommended that the System Director ensure that emergency procedures and contact information are posted and readily available to Clinic employees.
Closure Date:
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| 17-04460-84 | Combined Assessment Program Summary Report— Management of Disruptive and Violent Behavior in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure Facility Directors establish Employee Threat Assessment Teams.
Closure Date:
2 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require attendance by VA Police Officers, Patient Safety and/or Risk Management Officials, and Patient Advocates at Disruptive Behavior Committee/Board meetings and monitor compliance.
Closure Date:
3 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when Chiefs of Staff (or designees) issue Orders for Behavioral Restriction, they document that they informed patients that the Orders were issued and of the right to appeal the decisions and that facility senior managers monitor compliance.
Closure Date:
4 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require that within 90 days of hire, all employees complete Level I Prevention and Management of Disruptive Behavior training and additional training levels based on the type and severity of risk for exposure to disruptive and unsafe behaviors and monitor compliance.
Closure Date:
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14957