Recommendations
2111
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01856-135 | Comprehensive Healthcare Inspection Program Review of the Fayetteville VA Medical Center, North Carolina | 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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the Advisors’ compliance.
Closure Date:
3 The Facility Interim Director ensures that required representatives of the interdisciplinary group consistently attend meetings and review utilization management data, and monitors the group’s compliance.
Closure Date:
4 The Facility Interim Director ensures that 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 Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating patients on anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
6 The Chief of Staff ensures providers consistently document patient or surrogate informed consent and identify the receiving provider for patients transferred out of the facility and monitors the providers’ compliance.
Closure Date:
7 The Chief of Staff ensures that clinicians consistently communicate pertinent patient information to the receiving facility when patients are transferred out of the facility and monitors the clinicians’ compliance.
Closure Date:
8 The Associate Director ensures that 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 monitors compliance.
Closure Date:
9 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:
10 The Chief of Staff ensures that acceptable 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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| 17-05424-142 | Comprehensive Healthcare Inspection Program Review of the VA Illiana Health Care System, Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Service Chiefs complete all required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors the Service Chiefs’ compliance.
Closure Date:
2 The Chief of Staff ensures all required members attend the Utilization Management Committee meetings on an ongoing basis 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 Associate Director ensures that temperature monitoring occurs in all dry food storage areas and monitors compliance.
Closure Date:
5 The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Closure Date:
7 The Chief of Staff ensures ordering providers communicate mammogram results to patients and monitors providers’ compliance.
Closure Date:
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| 17-01764-143 | Comprehensive Healthcare Inspection Program Review of the Tennessee Valley Healthcare System, Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data every 6 months and monitors compliance.
Closure Date:
2 The Chief of Staff ensures Physician Utilization Management Advisors at the Alvin C. York campus consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
Closure Date:
3 The Facility Director ensures clinicians document patient education for patients receiving anticoagulation medication and monitors compliance.
Closure Date:
4 The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee and monitors compliance.
Closure Date:
5 The Chief of Staff ensures providers consistently document patient or surrogate informed consent and the patient’s medical and behavior stability when patients are transferred out of the facility and monitors the providers’ compliance.
Closure Date:
6 The Chief of Staff ensures providers countersign the acceptable designees’ transfer/progress notes when patients are transferred out of the facility and monitors compliance.
Closure Date:
7 The Associate Director ensures that environment of care rounds are conducted at the required frequency and correctly documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
8 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
9 The Associate Director ensures ventilation grills are clean and ceiling tiles are properly maintained and monitors compliance.
Closure Date:
10 The Chief of Staff ensures radiation safety signage is posted in each radiation area and monitors compliance.
Closure Date:
11 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
12 The Associate Director ensures all 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:
13 The Chief of Staff ensures that providers include review of abnormalities of major organ systems in the history and physical exams and/or pre-sedation assessments and monitors compliance.
Closure Date:
14 The Chief of Staff ensures that providers inform patients when the provider performing a moderate sedation procedure is not the provider listed on the informed consent for the procedure and document the patient’s assent to the change and monitors compliance.
Closure Date:
15 The Chief of Staff ensures clinical employees who perform, assist with, or supervise moderate sedation procedures have current moderate sedation training and monitors their compliance.
Closure Date:
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| 15-04678-114 | Review of Alleged Hazardous Construction Conditions at the Jack C. Montgomery VA Medical Center, Muskogee, Oklahoma | Audit | ||
1 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure contracting officer’s representatives comply with duties assigned in the Delegation of Authority Memo.
Closure Date:
2 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure that on future contracts, the Chief, Engineering Service, assign contracting officer’s representatives who have experience commensurate with delegated responsibilities in accordance with the Federal Acquisition Regulation.
Closure Date:
3 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure personnel follow established Veterans Health Administration policies on safety inspections.
Closure Date:
4 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, clarify the implementation of the safety inspections in Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017, to ensure the safety inspections are not performed routinely or in a discernable pattern.
Closure Date:
5 The OIG recommended the Medical Center Director, Eastern Oklahoma Department of Veterans Affairs Health Care System, ensure the assignment of a safety officer in accordance with Veterans Health Administration Directive 7715, Safety and Health During Construction, April 6, 2017.
Closure Date:
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| 17-05402-137 | Comprehensive Healthcare Inspection Program Review of the VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors members’ compliance.
Closure Date:
2 The Chief of Staff ensures the Infection Prevention Committee consistently documents discussions of the high-risk elements and analysis of surveillance data and monitors compliance.
Closure Date:
3 The Facility Director ensures that 1-day reconciliation of controlled substance refills to automated dispensing units in patient care areas and 1-day reconciliation of returns to pharmacy stock are performed consistently during controlled substance inspections, and the Facility Director monitors compliance.
Closure Date:
4 The Facility Director ensures that 72-hour pharmacy inventories are consistently completed during controlled substance inspections in pharmacy areas and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that the geriatric evaluation program receives the required oversight and that quality improvement data are regularly reviewed and documented in committee minutes, and the Chief of Staff monitors compliance.
Closure Date:
6 The Chief of Staff ensures that geriatric evaluation program registered nurses perform the required patient assessments and monitors the nurses’ compliance.
Closure Date:
7 The Chief of Staff ensures ordering providers or designees communicate mammogram results to patients within the required timeframe and monitors providers’ compliance.
Closure Date:
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| 17-00753-78 | Audit of the Personnel Suitability Program | Audit | ||
1 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness implement the monitoring program required by policy and establish robust management oversight of the personnel suitability program.
Closure Date:
2 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness report the results of program monitoring activities and obtain corrective action plans from the Veterans Health Administration.
Closure Date:
3 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness establish and enforce quality and performance metrics for the personnel suitability program.
Closure Date:
4 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness evaluate human capital needs for program oversight and facilitate the delegation or brokering of duties necessary to manage the background investigation workload.
Closure Date:
5 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness coordinate with the Executive in Charge, Office of the Under Secretary for Health, to implement a plan to review the suitability status of all Veterans Health Administration personnel and correct delinquencies to ensure a properly vetted workforce.
Closure Date:
6 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, improve management oversight of the personnel suitability program at VA medical facilities and ensure background investigations are properly initiated and adjudicated nationwide, and internal control mechanisms required by policy are properly implemented.
Closure Date:
7 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, execute VA requirements to improve the governance of the personnel suitability program.
Closure Date:
8 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, evaluate human capital needs and coordinate appropriate resources to manage personnel suitability workload at VA medical facilities.
Closure Date:
9 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness develop and execute a project management plan to ensure sufficient and appropriate data are collected in support of suitability program objectives.
Closure Date:
10 The OIG recommended the Assistant Secretary for Operations, Security, and Preparedness ensure that personnel suitability investigation data are fully evaluated and reliable for program tracking and oversight.
Closure Date:
11 The OIG recommended the Executive in Charge, Office of the Under Secretary for Health, coordinate with the Assistant Secretary for Operations, Security, and Preparedness to implement a plan to correct current data integrity issues and improve the accuracy of personnel suitability program data.
Closure Date:
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| 17-00253-102 | VHA Review of Selected Construction Projects at Oklahoma City VA Health Care System | Audit | ||
1 The OIG recommended the Acting Under Secretary for Health ensure the construction areas in the Surgical Intensive Care Unit project are sealed to prevent further weather damage.
Closure Date:
2 The OIG recommended the Acting Under Secretary for Health ensure the Oklahoma City VA Health Care System implements procedures to strengthen minor and non-recurring maintenance construction oversight.
Closure Date:
3 The OIG recommended the Acting Under Secretary for Health determine if administrative actions should be taken concerning key officials responsible for the Surgical Intensive Care Unit project.
Closure Date:
4 The OIG recommended the Acting Under Secretary for Health ensure the Oklahoma City VA Health Care System establishes procedures to ensure recommendations by technical experts, who perform site visits to evaluate project completion status and conformance to contract specifications as provided in design and construction contracts, are implemented.
Closure Date:
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| 17-01761-129 | Comprehensive Healthcare Inspection Program Review of the Providence VA Medical Center, Providence, Rhode Island | 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 Facility Director ensures the Patient Safety Manager conducts the minimum of four individual root cause analyses each year and monitors compliance.
Closure Date:
3 The Facility Director ensures the Patient Safety Manager prepares and submits annual patient safety reports and monitors the Patient Safety Manager’s compliance.
Closure Date:
4 The Chief of Staff ensures inter-facility patient transfer data are collected and analyzed as part of the facility’s quality management program and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that staff/attending physicians countersign transfer notes written by acceptable designees for patients transferring to another facility and monitors physicians’ compliance.
Closure Date:
6 The Chief of Staff ensures that facility staff consistently document provision of necessary medical care within the facility’s capacity for all patients prior to transfer to another facility and monitors staff compliance.
Closure Date:
7 The Chief of Staff ensures Radiology Service employees check the emergency cart and defibrillator according to facility policy and monitors compliance.
Closure Date:
8 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
9 The Associate 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 monitors members’ compliance.
Closure Date:
10 The Chief of Staff ensures the Community Nursing Home Oversight Committee meets at least quarterly, includes representatives from all required disciplines, and integrates the CNH program into the facility’s quality improvement program, and the Chief of Staff monitors the committee’s compliance.
Closure Date:
11 The Chief of Staff ensures the Community Nursing Home Review Team completes annual reviews within the required timeframe and monitors the team’s compliance.
Closure Date:
12 The Chief of Staff ensures social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitors social workers’ and registered nurses’ compliance.
Closure Date:
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| 16-04655-70 | Audit of VISN 7 Power Wheelchair and Scooter Repairs | Audit | ||
1 The OIG recommended the Veterans Integrated Service Network 7 Director require VA medical facility staff to input power wheelchair and scooter repair requests as soon as they are received and implement management controls to ensure repairs with closed consults are monitored to completion.
Closure Date:
2 The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service staff follow documentation procedures by making annotations in the consults as required by Veterans Health Administration Directive 1232(1), Consult Processes and Procedures, and the Prosthetic and Sensory Aids Service Business Practice Guidelines for Prosthetics Consult Management for power wheelchair and scooter repair.
Closure Date:
3 The OIG recommended the Veterans Integrated Service Network 7 Director implement controls to ensure Prosthetic Service staff monitor and follow up on repairs from initial request through completion to ensure the repairs are timely.
Closure Date:
4 The OIG recommended the Veterans Integrated Service Network 7 Director ensure Prosthetic Service managers and staff monitor vendors to ensure they meet agreed-upon delivery dates for repairs.
Closure Date:
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| 17-01854-115 | Comprehensive Healthcare Inspection Program Review of the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | 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 Facility Director ensures inter-facility patient transfer data are collected and reported to the Medical Executive Committee and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include documentation of patient or surrogate informed consent and identification of transferring and receiving provider or designee in transfer documentation and monitors the clinicians’ compliance.
Closure Date:
4 The Chief of Staff ensures that transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitors acceptable designees’ compliance.
Closure Date:
5 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:
6 The Deputy Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
Closure Date:
7 The Deputy Director ensures core team members consistently attend environment of care rounds and monitors compliance.
Closure Date:
8 The Deputy Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members receive annual training on the identification and correction of environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
9 The Chief of Staff ensures staff who perform, assist with, or supervise moderate sedation procedures have current Talent Management System moderate sedation training and monitors their compliance.
Closure Date:
10 The Associate Director for Patient Care Services 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 the social workers’ and registered nurses’ compliance.
Closure Date:
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