Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01744-69 | Comprehensive Healthcare Inspection Program Review of the Grand Junction Veterans Health Care System, Grand Junction, Colorado | 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 the Patient Safety Manager consistently provides feedback to employees or departments who submit close call and adverse event reports that result in a root cause analysis and monitors the manager’s compliance.
Closure Date:
3 The Chief of Staff ensures anticoagulation program managers establish a defined process for anticoagulation-related calls outside normal business hours and monitors compliance with the process.
Closure Date:
4 The Chief of Staff ensures the Pharmacy and Therapeutics Committee reviews anticoagulation data quarterly and monitors the committee’s compliance.
Closure Date:
5 The Facility Director ensures inter-facility patient transfer data are reported to a quality oversight committee and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include in transfer documentation patient or surrogate informed consent and monitors the clinicians’ compliance.
Closure Date:
7 The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently document sending or communicating pertinent patient information to the receiving facility and monitors the clinicians’ compliance.
Closure Date:
8 The Associate Director ensures core team members consistently attend environment of care rounds and monitors 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 how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors employees’ and team members’ compliance.
Closure Date:
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| 15-01005-18 | Audit of VHA's Use of Appropriations to Develop a System Enhancement and Mobile Health Application | Audit | ||
1 The OIG recommended the Acting Assistant Secretary for the Office of Information and Technology ensure the new directive reflects updates so that new and emerging advances in information technology are included.
Closure Date:
2 The OIG recommended the Acting Under Secretary for Health ensure VHA’s Chief Financial Officer, in consultation with VA’s Chief Financial Officer and Office of General Counsel, determine which medical care appropriation VHA should use for mobile health application development and notify VHA staff offices accordingly.
Closure Date:
3 The OIG recommended the Acting Assistant Secretary for the Office of Management issue a memorandum reiterating the importance of complying with the United States Code, Federal Regulations, and VA’s current policies on the proper use of appropriations.
Closure Date:
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| 16-02864-71 | Healthcare Inspection – Delays in Processing Release of Information Requests, Bay Pines VA Healthcare System, Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure strengthening of procedures for timely processing of Release of Information requests.
Closure Date:
2 We recommended that the System Director strengthen the process to adequately capture and trend complaints related to Release of Information requests in accordance with Veterans Health Administration policy.
Closure Date:
3 We recommended that the System Director ensure an evaluation of the personnel issues negatively impacting staff retention and hiring in the Release of Information section and take appropriate action.
Closure Date:
4 We recommended that the System Director ensure accurate monitoring of Release of Information staff productivity.
Closure Date:
5 We recommended that the System Director ensure accurate and effective trackingand monitoring processes of Release of Information requests.
Closure Date:
6 We recommended that the System Director ensure consultation with the Office ofHuman Resources and the Office of General Counsel to determine the appropriateadministrative action, if any, for managers’ performance related to implementation ofcorrective action plans in response to privacy violations.
Closure Date:
7 We recommended that the System Director ensure Release of Information standardoperating procedures are established in accordance with VHA policy and implemented consistently.
Closure Date:
8 We recommended that the System Director strengthen working relationships andcommunication processes within the facility Release of Information section andamongst staff and Business Office Service managers.
Closure Date:
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| 17-01740-62 | Comprehensive Healthcare Inspection Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director requires the Patient Safety Manager to ensure completion of the required minimum of eight root cause analyses each fiscal year.
Closure Date:
2 The Chief of Staff requires the Pharmacy and Therapeutics Committee to review all quality assurance data for the anticoagulation management program and monitors the committee’s 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 Chief of Staff ensures management-level representatives from all required disciplines consistently attend Community Nursing Home Oversight Committee meetings and monitors their compliance.
Closure Date:
5 The Chief of Staff ensures social workers conduct cyclical clinical visits with the required frequency and monitors the social workers’ compliance.
Closure Date:
6 The Chief of Staff ensures Mental Health Residential Rehabilitation Treatment Program employees perform and document weekly contraband inspections and monitors employees’ compliance.
Closure Date:
7 The Associate Director ensures that closed circuit television surveillance systems are repaired or replaced for all required areas in the Mental Health Residential Rehabilitation Treatment Program units.
Closure Date:
8 The Chief of Staff ensures the Mental Health Residential Rehabilitation Treatment Program units have signage alerting patients and visitors of closed circuit television recording.
Closure Date:
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| 17-01755-61 | Comprehensive Healthcare Inspection Program Review of the Minneapolis VA Health Care System, Minneapolis, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
Closure Date:
2 The Chief of Staff ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
Closure Date:
3 The Chief of Staff ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors advisors’ compliance.
Closure Date:
4 The Facility Director ensures the Patient Safety Manager submits an annual patient safety report to facility leaders at the completion of each fiscal year and monitors compliance.
Closure Date:
5 The Facility Director and Chief of Staff ensure that Executive Leadership Board and Peer Review Committee meeting minutes accurately reflect action status and that items are tracked to closure and monitor compliance.
Closure Date:
6 The Associate Director for Patient Care Services ensures the anticoagulation management program policy is revised to include the transition of patients between the inpatient and outpatient care settings and an anticoagulation quality assurance program.
7 The Chief of Staff and Associate Director for Patient Care Services ensure that anticoagulation management program quality assurance data from all sites of care are collected, analyzed, and reported biannually to the Pharmacy and Therapeutics Committee and monitor compliance.
Closure Date:
8 The Associate Director for Patient Care Services ensures that annual anticoagulation management program competency assessments include all required content and that employees assigned to this program complete competency assessments as required and monitors compliance.
Closure Date:
9 The Facility Director ensures the facility’s revised inter-facility transfer policy includes all required elements.
Closure Date:
10 The Chief of Staff ensures that for patients transferred out of the facility, providers consistently document patient or surrogate informed consent, medical and behavioral stability, and identification of transferring and receiving provider or designee and monitors providers’ compliance.
11 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 compliance.
12 The Associate Director for Operations ensures designated team members conduct environment of care rounds in clinical and nonclinical areas as required and monitors compliance.
Closure Date:
13 The Associate Director for Operations ensures all locked mental health unit employees and 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:
14 The Chief of Staff ensures that providers include an airway assessment and history of previous adverse experience with sedation or anesthesia in the history and physical exam and/or pre-sedation assessment and monitors the providers’ compliance.
Closure Date:
15 The Chief of Staff ensures that providers provide and document informed consent prior to moderate sedation administration and monitors providers’ compliance.
Closure Date:
16 The Chief of Staff ensures clinical teams conduct and document timeouts prior to moderate sedation procedures, the privileged provider participates in the timeout, and staff use a checklist that includes all required elements and monitors compliance.
Closure Date:
17 The Chief of Staff ensures Community Nursing Home Oversight Committee meetings include participation by all required disciplines and monitors compliance.
Closure Date:
18 The Associate Director for Patient Care Services ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.
Closure Date:
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| 16-00928-391 | Audit of Medical Support Assistant Workforce Management at the Phoenix VA Health Care System | Audit | ||
1 The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements controls to make sure sufficient information on the outpatient Medical Support Assistant workforce is captured and documented to allow leadership to align strategically this workforce with outpatient clinical operations.
Closure Date:
2 The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements mechanisms to make certain that Human Resources Management Service personnel record complete and accurate Medical Support Assistant recruitment and hiring data and documentation in the USA Staffing System.
Closure Date:
3 The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System leverages available incentives to the extent practicable to recruit and retain qualified applicants for human resources specialist positions.
Closure Date:
4 The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements the Hire Right Hire Fast program’s best practices to improve the timeliness of the Medical Support Assistant selection process.
Closure Date:
5 The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System implements controls to make certain newly hired Medical Support Assistants are provided with timely performance plans in accordance with VA Handbook 5013/12.
Closure Date:
6 The OIG recommended the Veterans Integrated Service Network 22 Director ensures that the director of the Phoenix VA Health Care System evaluates the feasibility of using available employee survey data to identify and redress the reasons why Medical Support Assistants leave their current positions.
Closure Date:
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| 17-01852-59 | Comprehensive Healthcare Inspection Program Review of the South Texas Veterans Health Care System, San Antonio, Texas | Comprehensive Healthcare Inspection Program | ||
1 The Assistant Director ensures damaged sink counters on the cardiac intensive care unit are repaired.
Closure Date:
2 The Chief of Staff and Associate Director for Patient Care Services ensure locked mental health unit employees and 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 monitor compliance.
Closure Date:
3 The Associate Director for Patient Care Services ensures social workers and registered nurses conduct cyclical clinical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitors their compliance.
Closure Date:
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| 16-03576-53 | Healthcare Inspection - Patient Mental Health Care Issues at a Veterans Integrated Service Network 16 Facility | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure usage of only approved policies regarding use of benzodiazepines and facility managers monitor compliance.
Closure Date:
2 We recommended that the Facility Director ensure facility managers revise the patient complaint policy to include the VHA requirement for a clinical appeals process and to educate clinicians about the VHA requirement for clinical appeals and monitor compliance.
Closure Date:
3 We recommended that the Facility Director ensure that the Psychosocial Residential Rehabilitation Treatment Program committee admission screening process isappropriate and timely and that facility managers monitor compliance.
Closure Date:
4 We recommended that the Facility Director ensure that mental health clinicians administer tuberculosis tests (purified protein derivative) when needed forPsychosocial Residential Rehabilitation Treatment Program admission and that facility managers monitor compliance.
Closure Date:
5 We recommended that the Facility Director ensure that Mental Health services areprovided timely for patients designated as high risk for suicide that have beenrecently discharged from community hospitals.
Closure Date:
6 We recommended that the Facility Director ensure that non-VA care for psychiatricservices is offered to patients who need to be seen sooner than VA appointmentavailability permits.
Closure Date:
7 We recommended that the Facility Director request that the Veterans IntegratedService Network Mental Health Program Manager evaluate facility Mental HealthServices and programs for opportunities for improvement.
Closure Date:
8 We recommended that the Facility Director ensure that a Mental Health Treatment Coordinator policy is implemented as required by the Veterans Health Administrationand that all patients receiving mental health services are assigned a Mental Health Treatment Coordinator.
Closure Date:
9 We recommended that the Facility Director ensure compliance with medication reconciliation as required by facility policies.
Closure Date:
10 We recommended that the Facility Director ensure that Suicide Behavior Reports are completed for all patient suicide attempts and that the Patient Safety Manager is added as a signer as required by facility policy.
Closure Date:
11 We recommended that the Facility Director ensure that a peer review screening is completed for patients who have attempted suicide within 30 days of seeing a health care professional as required by facility policy.
Closure Date:
12 We recommended that the Facility Director initiate an external peer review to determine whether mental health staff appropriately managed the patient’s bipolar illness. Based on the results of that peer review, the Facility Director should consult with the Office of Chief Counsel regarding an institutional disclosure, if appropriate.
Closure Date:
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| 17-01741-58 | Comprehensive Healthcare Inspection Program Review of the New Mexico VA Health Care System, Albuquerque, New Mexico | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data quarterly and monitors the managers’ compliance.
Closure Date:
2 The Associate Director for Patient Care Services ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
Closure Date:
3 The Associate Director ensures quality assurance data for the anticoagulation management program are reviewed at the Pharmacy and Therapeutics Committee and monitors compliance.
Closure Date:
4 The Chief of Staff ensures clinicians provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
5 The Chief of Staff ensures clinicians obtain required laboratory tests prior to initiating anticoagulant medications and monitors the clinicians’ compliance.
Closure Date:
6 The Associate Director ensures all required elements specific to anticoagulation management are included in competency assessments for all employees actively involved in the anticoagulant program and monitors compliance.
Closure Date:
7 The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee assigned these responsibilities and monitors compliance.
Closure Date:
8 The Associate Director for Patient Care Services ensures providers consistently document patient or surrogate informed consent and patient medical and behavioral stability and identify transferring providers or designees for patients transferred out of the facility and monitors providers’ compliance.
Closure Date:
9 The Associate Director for Patient Care Services ensures that, for inter-facility transfers, providers document sending or communicating to the accepting facility pertinent patient information and monitors compliance.
Closure Date:
10 The Assistant Director ensures environment of care inspections are conducted at the required frequency and documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
11 The Assistant Director ensures core team members consistently participate in environment of care rounds and attendance is documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
12 The Assistant Director ensures that in patient care areas, floors and rolling equipment are clean, nourishment kitchen ice machines are clean, and damaged furniture is repaired or removed from service and monitors compliance.
Closure Date:
13 The Assistant Director ensures outdated supplies are removed from the Santa Fe VA Clinic and monitors compliance.
Closure Date:
14 The Assistant Director ensures facility managers complete a physical security assessment for the locked geriatric mental health unit.
Closure Date:
15 The Assistant Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on how to identify and correct environmental hazards, to include the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
16 The Chief of Staff ensures that providers include the accurate name of the provider performing the procedure on the informed consent and monitors providers’ compliance.
Closure Date:
17 The Chief of Staff ensures the privileged providers performing the procedure participate in the timeout process prior to moderate sedation procedures and monitors providers’ compliance.
Closure Date:
18 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 compliance.
Closure Date:
19 The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by all required disciplines and monitors compliance.
Closure Date:
20 The Chief of Staff ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.
Closure Date:
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| 16-03705-60 | Healthcare Inspection – Alleged Women’s Health Care Issues, Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that system primary care providers receive education on Veterans Health Administration cervical cancer screening guidelines and that supervisors monitor compliance.
Closure Date:
2 We recommended that the System Director review and evaluate the routine use of general anesthesia for loop electrosurgical excision procedures conducted in the operating room and take action as appropriate.
Closure Date:
3 We recommended that the System Director utilize Veterans Health Administration resources to promote a culture that discourages behaviors that undermine safe patient care and effective communication and collaboration between providers and between providers and patients.
Closure Date:
4 We recommended that the System Director ensure that care coordination agreements between primary care and gynecology services meet system annual review requirements.
Closure Date:
5 We recommended that the System Director ensure that Patient Advocacy Program managers enter all complaints into the Patient Advocacy Tracking System database and track all reported complaints to resolution.
Closure Date:
6 We recommended that the System Director ensure that system gynecologists have current privileges that meet Veterans Health Administration and system policy requirements.
Closure Date:
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14957