Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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13 The Assistant Director ensures outdated supplies are removed from the Santa Fe VA Clinic and monitors compliance.
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14 The Assistant Director ensures facility managers complete a physical security assessment for the locked geriatric mental health unit.
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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.
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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.
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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.
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19 The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by all required disciplines and monitors compliance.
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20 The Chief of Staff ensures the social workers and registered nurses conduct monthly cyclical clinical visits and monitors compliance.
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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.
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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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| 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.
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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.
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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.
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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.
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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.
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9 We recommended that the Facility Director ensure compliance with medication reconciliation as required by facility policies.
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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.
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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.
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| 17-02375-50 | Administrative Investigation – Improper Locality Pay, Office of the General Counsel, Pacific District South, Phoenix, Arizona | Administrative Investigation | ||
1 We recommend that the General Counsel determine whether Ms. (redacted) official duty station from July 2016 to December 2016 was Phoenix or Los Angeles.
Closure Date:
2 We recommend that if the General Counsel determines Ms. (redacted) official duty station from July 2016 to December 2016 was Phoenix, determine the total amount of locality pay improperly paid to her, and issue her a bill of collection in that amount.
Closure Date:
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| 16-02552-49 | Administrative Investigation – Improper Relocation Allowance and Market Pay, Veterans Health Administration, Washington, DC | Administrative Investigation | ||
1 We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Dr. West.
Closure Date:
2 We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Dr. Lynch.
Closure Date:
3 We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of General Counsel and Human Resources and issue Dr. West a bill of collection in the amount of $19,800 to reimburse VA for the lump sum TQSE payment he received but did not incur.
Closure Date:
4 We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of General Counsel and Human Resources and issue Dr. West a bill of collection in the amount of $55,434 to reimburse VA for the increase salary he received based on Washington, DC, market pay, from September 2013 to October 2016, when he was actually located in Salt Lake City, UT.
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| 15-03036-47 | Audit of VHA’s Timeliness and Accuracy of Choice Payments Processed Through FBCS | Audit | ||
1 We recommended the Executive in Charge, Veterans Health Administration, develop and issue written payment policies to guide staff processing medical claims received from Third Party Administrators, as well as establish expectations and obligations for the Third Party Administrators that submit invoices for payment.
Closure Date:
2 We recommended the Executive in Charge, Veterans Health Administration, ensure payment processing staff have access to documentation from the Third Party Administrators verifying amounts paid to providers to ensure the Third Party Administrators are not billing VA more than they paid the provider for medical claims.
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3 We recommended the Executive in Charge, Veterans Health Administration, ensure Veterans Health Administration payment staff have access to accurate data regarding veterans’ other health insurance coverage and establish appropriate processes for collecting payments from these health insurers.
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4 We recommended the Executive in Charge, Veterans Health Administration, ensure the new payment processing systems used for processing medical claims from Third Party Administrators have the ability to adjudicate reimbursement rates accurately and to ensure duplicate claims are not paid.
Closure Date:
5 We recommended the Executive in Charge, Veterans Health Administration, ensure VA performs post-payment audits on a periodic basis to determine if payments made to Third Party Administrators for medical care are accurate.
Closure Date:
6 We recommended the Executive in Charge, Veterans Health Administration, ensure that Office of Community Care staff and members of VA’s Office of General Counsel continue to work collaboratively with relevant Government authorities to review and determine an appropriate process for reimbursement.
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7 We recommended the Executive in Charge, Veterans Health Administration, ensure the Veterans Health Administration has sufficient claims processing capacity to timely meet and process expected claim volume from the Third Party Administrators.
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8 We recommended the Executive in Charge, Veterans Health Administration, ensure that future contracts with Third Party Administrators contain payment timeliness standards for the processing of claims from health care providers.
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| 17-01849-42 | Comprehensive Healthcare Inspection Program Review of the John D. Dingell VA Medical Center, Detroit, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data every 6 months and monitors the managers’ compliance.
Closure Date:
2 The Chief of Staff and Associate Director for Patient Care Services ensure clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitor clinicians’ compliance.
Closure Date:
3 The Associate Director for Patient Care Services ensures clinical managers include in 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 Associate Director for Patient Care Services monitors managers’ compliance.
Closure Date:
4 The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
Closure Date:
5 The Associate Director ensures damaged furnishings in patient care areas are repaired or removed from service.
Closure Date:
6 The Associate Director ensures panic alarms at the Veterans Community Resource and Referral Center are tested and testing is documented and monitors compliance.
Closure Date:
7 The Associate Director ensures radiation shields and aprons have evidence of periodic inspection and testing for integrity and monitors compliance.
Closure Date:
8 The Associate Director ensures radiology equipment consistently receives annual inspection by a medical physicist and monitors compliance.
Closure Date:
9 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 team members’ compliance.
Closure Date:
10 The Chief of Staff 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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| 15-05447-383 | Review of Alleged Mismanagement of VA’s Real Time Location System Project | Audit | ||
1 The OIG recommended that the Acting Under Secretary for Health, in conjunction with the Acting Assistant Secretary for Information and Technology, apply additional resources and implement improved integrated project management controls for the remainder of the Real Time Location System project to restrict further cost increases.
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2 The OIG recommended that the Acting Under Secretary for Health, in conjunction with the Acting Assistant Secretary for Information and Technology, enforce the use of incremental project management controls, such as those used within the Veteran-focused Integration Process, on all remaining Real Time Location System task orders to ensure such efforts will provide an adequate return on investment.
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3 The OIG recommended the Acting Assistant Secretary for the Office of Information and Technology ensure that risk assessments are conducted on future Real Time Location System deployments to identify potential risks and vulnerabilities that may adversely affect other VA systems.
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| 16-00471-10 | Audit of VHA's Alleged Beneficiary Travel Processing Irregularities at the VAMC in Phoenix, Arizona | Audit | ||
1 We recommended the Director of the Carl T. Hayden VA Medical Center develop and implement written procedures requiring Beneficiary Travel Program and Fiscal Service staff to perform appropriate actions in response to electronic alerts notifying them of potential duplicate claims and payments.
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2 We recommended the Director of the Carl T. Hayden VA Medical Center develop and implement a quality review program to routinely ensure Beneficiary Travel Program staff document and use physical addresses when calculating mileage reimbursements.
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15039