Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 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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| 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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| 17-01744-69 | 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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15039