Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-02686-125 | Healthcare Inspection – Alleged Patient Aligned Care Team Wait Time and Funding Issues at the Monterey Community Based Outpatient Clinic, VA Palo Alto Health Care System, Palo Alto, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director review human resources and clinic hiring processes for Patient Aligned Care Team staff and take action to minimize delays in filling vacancies.
Closure Date:
2 We recommended that the System Director assess and ensure patient panel sizes for Patient Aligned Care Team providers are in compliance with Veterans Health Administration policy.
Closure Date:
3 We recommended that the System Director ensure that Patient Aligned Care Team process improvement projects do not negatively affect clinic patient appointments.
Closure Date:
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| 17-02644-130 | Critical Deficiencies at the Washington DC VAMC | Hotline Healthcare Inspection | ||
1 The Medical Center Director ensures that necessary supplies, instruments, and equipment are available in patient care areas at the Medical Center when and where they are needed.
Closure Date:
2 The Medical Center Director requires operating room staff to conduct the final validation that all supplies, instruments, and equipment needed to perform the planned procedure and to address potential complications are in the operating room and available for use.
Closure Date:
3 The Medical Center Director makes certain that the OR staff have accurate lists of surgical instruments needed for particular procedures.
Closure Date:
4 The Under Secretary for Health specifies criteria under which individual medical centers will conduct wild card Aggregated Reviews for high-frequency patient safety events.
Closure Date:
5 The Medical Center Director ensures that routine audits of incident reporting system entries are completed to ascertain that all patient safety events are in the National Center for Patient Safety database as required by VHA policy.
Closure Date:
6 The Medical Center Director requires Medical Center oversight committees to follow up and initiate action as necessary on quality assurance matters related to supplies, instruments, or equipment.
Closure Date:
7 The Medical Center Director confirms the full utilization of a VHA authorized inventory system that contains accurate and reliable information regarding the availability of supplies throughout the Medical Center.
Closure Date:
8 The Medical Center Director makes certain that the environmental integrity of clean/sterile storerooms complies with VHA policy.
Closure Date:
9 The Medical Center Director ensures there are clearly defined and effective procedures for replacing missing or broken instruments, and that staff responsible for this function have been educated on the process.
Closure Date:
10 The Medical Center Director confirms that clearly defined and effective procedures address the disposition of discolored instruments during reprocessing and that staff responsible for this function have been educated on the process.
Closure Date:
11 The Medical Center Director ensures that the Sterile Processing Service (SPS) implements a quality assurance program to verify the cleanliness, functionality, and completeness of instrument sets prior to their reaching clinical areas.
Closure Date:
12 The Medical Center Director makes certain that SPS and OR personnel comply with policies and procedures for the proper reprocessing of loaner instruments and trays.
Closure Date:
13 The Medical Center Director verifies that SPS managers maintain an accurate Master List for reusable medical equipment and file copies of manufacturer’s instructions as required by VHA policy.
Closure Date:
14 The Medical Center Director ensures that the SPS maintains updated and readily accessible standard operating procedures for all instruments and equipment within SPS and its satellite areas in accordance with VHA policy.
Closure Date:
15 The Medical Center Director verifies that all SPS employees have appropriate, updated competencies and a demonstrated proficiency to perform their assigned duties.
Closure Date:
16 The VISN 5 Director secures adequate space and funding for the Medical Center satellite reprocessing areas, which includes separate decontamination, processing, and packaging areas in accordance with VHA SPS policies.
Closure Date:
17 The VISN 5 Director makes certain that the Medical Center Director resolves open and pending prosthetic consults and implements a plan to address future prosthetic consults in accordance with VHA policy.
Closure Date:
18 The Medical Center Director ensures the revision of Medical Center Fiscal Service practices to eliminate unnecessary cessations of prosthetic device purchasing, including at fiscal year-end.
Closure Date:
19 The VISN 5 Director, together with Medical Center leaders, develops a staffing plan to fill vacancies that includes accurate numbers of authorized positions by service that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
Closure Date:
20 The VISN 5 Director ensures the timely completion of hiring actions at the Medical Center until staffing deficiencies in Logistics Service and Sterile Processing Services are fully resolved.
Closure Date:
21 The Medical Center Director transitions purchase cards held by clinical staff and used for expendable medical supplies to Logistics Service staff, while ensuring that medical supplies can be obtained in a timely manner.
Closure Date:
22 The Medical Center Director ensures that medical supply items are added to the prime vendor formulary in order to meet prime vendor purchasing goals.
Closure Date:
23 The Medical Center Director makes certain that the Purchase Card Coordinator and approving officials monitor the issuance and future use of government purchase cards in accordance with VA Financial Policy.
Closure Date:
24 The Medical Center Director maintains segregation of duties between personnel who order and purchase expendable and nonexpendable items and those who receive the items.
Closure Date:
25 The VISN 5 Director ensures that the Medical Center updates and maintains the Equipment Inventory List (EIL) as required by VA policy and makes certain that the Medical Center Director and Chief Logistics Officer are held accountable for the timely and accurate reporting of the Medical Center EIL.
Closure Date:
26 The Medical Center Director ensures that equipment is accurately and timely entered into the Automated Engineering Management System/Medical Equipment Reporting System.
Closure Date:
27 The Medical Center Director ensures that unrequired equipment is turned in for disposition consistent with VHA policies and procedures
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28 The Medical Center Director properly secures all areas used to store medical equipment and supplies.
Closure Date:
29 The Medical Center Director designates an official records manager, alternate records manager, and official records liaisons, as well as implements a records management program in accordance with the National Archives and Records Administration requirements.
Closure Date:
30 The Medical Center Director verifies that actions have been taken to notify patients when their information may have been improperly accessed, as appropriate.
Closure Date:
31 The Medical Center Director verifies that accurate and complete financial documentation to support medical supply and equipment purchases is readily available in accordance with GAO Standards for Internal Control in the Federal Government.
Closure Date:
32 The VISN 5 Director audits a representative sample of FY 2017 Medical Center supply, instrument, and equipment purchases and ensures adequate internal controls for future purchases are in place.
Closure Date:
33 The Deputy Under Secretary for Health for Operations and Management ensures that the VHA Procurement and Logistics Office conducts regular audits of the logistics services within VHA medical centers to assess compliance with VA and VHA policies pertaining to procurement and logistics, and makes certain that timely and effective remediation occurs in response to all noncompliant conditions identified as a result of those audits.
Closure Date:
34 The VISN 5 Director evaluates the accuracy of representations made by Medical Center staff in connection with the completion of action plans arising out of the National Program Office of Sterile Processing October 2016 site visit and determines whether administrative actions should be taken as a result of those representations.
Closure Date:
35 The VISN 5 Director institutes procedures designed to ensure the accuracy of future representations made by Washington DC VA Medical Center staff in connection with action plans submitted to oversight bodies such as VHA program offices.
Closure Date:
36 The Under Secretary for Health clearly defines program offices’ responsibility for reporting high-priority recommendations to responsible individuals within VHACO, and requires independent verification that the relevant medical center and/or VISN have implemented the recommendations.
Closure Date:
37 The Under Secretary for Health develops a means of aggregating and analyzing available data on Logistics, Sterile Processing, Prosthetics, and Human Resources services (or other services as the Under Secretary for Health deems appropriate) so that major operational deficiencies at a medical center or VISN that affect multiple services or functions may be detected and corrected.
Closure Date:
38 The Under Secretary for Health takes appropriate administrative action to address the conditions identified in this report.
Closure Date:
39 The VISN 5 Director oversees implementation of recommendations directed to the Medical Center Director.
Closure Date:
40 The Under Secretary for Health verifies the successful implementation of all recommendations contained within this report.
Closure Date:
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| 16-00409-64 | Audit of Interior Design and Furnishing Contract Mismanagement by Network Contracting Office 21 | Audit | ||
1 The OIG recommended Service Area Office West Executive Director ensure the Network Contracting Office 21 Director implements the required integrated oversight process to perform the required pre-award contract reviews to ensure contracting officers’ compliance with Federal and VA acquisition regulations prior to contract award.
Closure Date:
2 The OIG recommended the Veterans Integrated Service Network 21 Director consult with the appropriate VA financial and legal officials to determine steps the Northern California Health Care System Director should take to remedy the violation of the bona fide needs rule.
Closure Date:
3 The OIG recommended the Service Area Office West Executive Directortake steps to ensure the Network Contracting Office 21 Director developand implement processes to effectively monitor the status of contractsand ensure contracting officers appropriately modify the contracts orclose them out in accordance with contract terms and the FederalAcquisition Regulation.
Closure Date:
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| 17-01491-112 | Healthcare Inspection—Quality of Care and Patient Safety Concerns in the Community Living Center, James A. Haley VA Hospital, Tampa, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Community Living Center and Emergency Department staff understand and comply with policies for communication about residents requiring evaluation and treatment.
Closure Date:
2 We recommended that the Facility Director ensure that Community Living Center leaders develop a system to ensure fall precautions identified in the Falls Assessment are consistently reflected in the Individual Care Plan and implemented accordingly, and that staff are held accountable.
Closure Date:
3 We recommended that the Facility Director ensure the availability and functionality of fall prevention and safety devices such as hip protectors and chair alarms.
Closure Date:
4 We recommended that the Facility Director ensure that Community Living Center leaders follow through on efforts to determine staff knowledge deficits related to fall prevention and institute training and process improvements.
Closure Date:
5 We recommended that the Facility Director ensure that Community Living Center leaders conduct appropriate reviews and implement required actions in cases of suspected abuse or neglect.
Closure Date:
6 We recommended that the Facility Director ensure an adequate nurse staffing mix to meet the acuity levels and needs of the Community Living Center’s residents.
Closure Date:
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| 17-01746-116 | Comprehensive Healthcare Inspection Program Review of the Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that a senior-level committee is established and responsible for key Quality, Safety, and Value functions.
Closure Date:
2 The Facility Director ensures the Patient Safety Manager completes the required minimum of eight root cause analyses each fiscal year and monitors the manager’s compliance.
Closure Date:
3 The Chief of Staff ensures that anticoagulation management program quality assurance data are analyzed and reported to the Pharmacy and Therapeutics Committee and monitors program managers’ compliance.
Closure Date:
4 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians' compliance.
Closure Date:
5 The Chief of Staff ensures clinicians consistently obtain and document all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians' compliance.
Closure Date:
6 The Chief of Staff ensures all required elements specific to anticoagulation management are included in competency assessments for employees actively involved in the anticoagulant program and monitors compliance.
Closure Date:
7 The Associate Director ensures environment of care inspections are conducted at the required frequency and monitors compliance.
Closure Date:
8 The Associate Director ensures core team members consistently participate in environment of care rounds and monitors compliance.
Closure Date:
9 The Chief of Staff and the Nurse Executive ensure that the Community Nursing Home Oversight Committee includes representation by all required disciplines and monitor compliance
Closure Date:
10 The Nurse Executive ensures social workers conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitors social workers’ compliance.
Closure Date:
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| 17-01758-104 | Comprehensive Healthcare Inspection Program Review of the Hampton VA Medical Center, Hampton, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers communicate to the Peer Review Committee all completions of individual improvement actions and monitors managers’ compliance.
Closure Date:
2 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data with the frequency required by facility policy and monitors the managers’ compliance.
Closure Date:
3 The Chief of Staff requires clinicians to ensure patients with newly prescribed warfarin have international normalized ratio measurements taken within 7 days of warfarin initiation, and monitor compliance.
Closure Date:
4 The Chief of Staff requires clinical managers to complete competency assessments annually for employees actively involved in the anticoagulant program and monitors managers’ compliance.
Closure Date:
5 The Chief of Staff ensures clinicians consistently include identification of the receiving provider in transfer documentation and monitors the clinicians’ compliance.
Closure Date:
6 The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
Closure Date:
7 The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
Closure Date:
8 The Associate Director ensures the Chesapeake community based outpatient clinic panic alarms are tested monthly and monitors compliance.
Closure Date:
9 The Associate Director ensures storage carts and shelves at the Chesapeake Community Based Outpatient Clinic have solid bottom shelves and monitors compliance.
Closure Date:
10 The Associate Director ensures locked mental health unit panic alarm testing includes documentation of VA Police response time and monitors compliance.
Closure Date:
11 The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
Closure Date:
12 The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training for identification and correction of environmental hazards and proper use of the Mental Health Environment of Care Checklist and monitors compliance.
Closure Date:
13 The Chief of Staff ensures providers include a history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and monitors providers’ compliance.
Closure Date:
14 The Chief of Staff ensures that physicians who perform or assist with moderate sedation procedures receive training for the provision of moderate sedation care prior to being re-privileged and that training is documented and monitors compliance with training and documentation.
Closure Date:
15 The Facility Director ensures that the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates processes into the facility’s quality improvement program with documentation of these processes in the facility’s executive-level committee meeting minutes and monitors compliance.
Closure Date:
16 The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and submits exclusionary criteria exemption requests when a community nursing home meets the threshold of four or more deficiencies and monitors the team’s compliance.
Closure Date:
17 The Chief of Staff ensures 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 monitors social workers’ and registered nurses’ compliance.
Closure Date:
18 The Associate Director ensures that Domiciliary Care for Homeless Veterans Program, general domiciliary, and Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees conduct and document daily resident room inspections for unsecured medications and monitors employees’ compliance.
Closure Date:
19 The Associate Director ensures that adequate security surveillance is provided through functional and regularly tested equipment and monitors compliance.
Closure Date:
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| 15-01580-108 | Healthcare Inspection - Review of Montana Board of Psychologists Complaint and Assessment of VA Protocols for Traumatic Brain Injury Compensation and Pension Examinations | National Healthcare Review | ||
1 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to ensure that personnel performing the traumatic brain injury Compensation and Pension examination have comprehensive training on the evaluation of traumatic brain injury, including the assessment and evaluation of cognitive disorders.
Closure Date:
2 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to develop requirements for documentation of the traumatic brain injury Compensation and Pension examination process, including the basis for determinations of cognitive impairment and other residuals of traumatic brain injury.
Closure Date:
3 We recommended that the Executive in Charge, Office of the Under Secretary for Health and Acting Under Secretary for Benefits convene experts to develop a plan to consider whether to provide disability ratings to veterans with claims arising from cognitive issues based upon their clinical signs and symptoms, not primarily based upon the diagnosis or cause of their cognitive deficits (that is. traumatic brain injury or post-traumatic stress disorder).
Closure Date:
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| 17-02678-107 | Healthcare Inspection—Alleged Failure in Patient Notification of Test Results, VA Connecticut Healthcare System, West Haven, Connecticut | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure providers follow the Veterans Health Administration policy related to patient notification of test results.
Closure Date:
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| 17-01750-97 | Comprehensive Healthcare Inspection Program Review of the VA Northern California Health Care System, Mather, California | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors reviewers’ compliance.
Closure Date:
2 The Chief of Staff ensures service chiefs consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors the service chiefs’ compliance.
Closure Date:
3 The Chief of Staff ensures pharmacy managers implement an anticoagulation management standard operating procedure that contains all elements required by the Veterans Health Administration.
Closure Date:
4 The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
5 The Chief of Staff ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
Closure Date:
6 The Chief of Staff ensures clinicians consistently include patient or surrogate informed consent in transfer documentation and monitors clinicians’ compliance.
Closure Date:
7 The Associate Directors ensure required team members participate on environment of care rounds and monitor compliance.
Closure Date:
8 The Associate Director ensures VA Police conduct required testing of the locked mental health unit security surveillance television system and monitors VA Police compliance.
Closure Date:
9 The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
10 The Chief of Staff ensures providers include the history of previous experience with sedation and anesthesia in the history and physical exams and/or pre-sedation assessments and monitors compliance.
Closure Date:
11 The Chief of Staff ensures clinical teams use a checklist that includes all required elements to conduct and document timeouts prior to moderate sedation procedures and monitors the teams’ compliance.
Closure Date:
12 The Chief of Staff ensures the Community Nursing Home Review Team completes required annual reviews and monitors the team’s compliance.
Closure Date:
13 The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required and monitors social workers’ and registered nurses’ compliance.
Closure Date:
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| 17-05909-106 | Administrative Investigation – VA Secretary and Delegation Travel to Europe | Administrative Investigation | ||
1 Secretary Shulkin reimburses the $4,312 paid by VA to cover Dr. Bari’s travel costs.
Closure Date:
2 Secretary Shulkin consults with the Office of General Counsel to determine the value of the Wimbledon tickets; grounds pass; and any food, parking, and other tangible benefits Ms. Gosling provided in connection with Wimbledon and reimburse that amount to her. If Ms. Gosling declines to accept reimbursement, Secretary Shulkin reimburses such amount to the US Treasury.
Closure Date:
3 The Deputy Secretary of Veterans Affairs confers with the Offices of General Counsel, Human Resources, and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against Ms. Wright Simpson and any other individuals associated with the Europe trip.
Closure Date:
4 The Deputy Secretary of Veterans Affairs ensures that a thorough audit is conducted of the expense vouchers, travel authorizations, and the time and attendance records for all travelers on the Europe trip. Any overpayments should be reimbursed to VA by the traveler and any required leave adjustments should be made. Detailed results of the audits, including supporting documentation, shall be provided to the Office of Inspector General no later than thirty days following the publication of this report.
Closure Date:
5 The Deputy Secretary of Veterans Affairs ensures that the Office of General Counsel (i) reviews and enhances the training provided to staff on travel planning, approvals, and the solicitation or acceptance of gifts; and (ii) provides refresher training on these topics to all travelers on the Europe trip as well as all staff involved in the planning and implementation of the trip.
Closure Date:
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15039