Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-04208-30 | Healthcare Inspection—Unexpected Death of a Patient: Alleged Methadone Overdose, Grand Junction VA Health Care System, Grand Junction, CO | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that providers who prescribe methadone receive education on VA/DoD Clinical Practice Guideline recommendations related to the use of methadone for the management of chronic pain.
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2 We recommended that the System Director develop a process to ensure that providers consider VA/DoD Clinical Practice Guideline recommendations, specifically the use of electrocardiograms, in their clinical decision to prescribe methadone for chronic pain management.
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3 We recommended that the System Director ensure that patients receiving methadone be informed, not only of complications related to opioids but also, complications specific to methadone and that this discussion is documented.
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4 We recommended that the System Director ensure that the consent form for patients receiving methadone for chronic pain management be modified to include methadone-specific risks.
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5 We recommended that the System Director confer with the Office of Chief Counsel regarding the patient described in this report for possible institutional disclosure to the designated family member(s), and take action as appropriate.
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| 17-01739-31 | Comprehensive Healthcare Inspection Program Review of the VA Long Beach Healthcare System, Long Beach, California | 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.
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2 The Associate Director for Patient Care Services ensures clinical managers include all required elements in competency assessments for employees actively involved in the anticoagulant program and monitors managers’ compliance.
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3 The Chief of Staff ensures that for patients transferred out of the facility, providers consistently include patient or surrogate informed consent and medical and/or behavioral stability in transfer documentation and monitors providers’ compliance
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4 The Chief of Staff ensures transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitors acceptable designees’ compliance
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5 The Chief of Staff 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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6 The Assistant Director ensures that facility managers maintain a safe and clean environment throughout the facility and the Santa Ana Outpatient Primary Care Clinic and monitors the managers’ compliance.
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7 The Chief of Staff ensures that facility managers conduct annual infection prevention risk assessments.
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8 The Assistant Director ensures that dirty and used equipment is stored separately from sterile supplies.
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9 The Assistant Director ensures that staff regularly test panic alarms at the Santa Ana Outpatient Primary Care Clinic.
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10 The Assistant Director ensures that staff regularly test camera surveillance equipment on the locked mental health unit and monitors compliance.
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11 The Assistant Director ensures that the locked mental health unit clean/sterile supply rooms are clean and that used equipment is stored separately from sterile supplies.
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12 The Chief of Staff and Associate Director for Patient Care Services ensure the Community Nursing Home Oversight Committee includes representation by all required disciplines.
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13 The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.
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14 The Associate Director for Patient Care Services ensures that the social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitors the social workers’ and registered nurses’ compliance.
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| 17-01751-25 | Comprehensive Healthcare Inspection Program Review of the James J. Peters VA Medical Center, Bronx, New York | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures the Quality Executive Board meets monthly as required by facility policy, or facility leaders revise the local policy to be consistent with Veterans Health Administration quarterly meeting requirements, and the Facility Director monitors compliance.
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2 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data twice per year and monitors the managers’ compliance.
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3 The Facility Director ensures clinical managers complete at least 75 percent of allrequired inpatient utilization management reviews and monitors the managers’compliance.
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4 The Facility Director ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
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5 The Chief of Staff ensures identification of an interdisciplinary group or committee, ensures review of utilization management data on an ongoing basis, and monitors the group’s compliance with data review policies.
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6 The Facility Director ensures all required anticoagulation management programquality assurance data are collected, analyzed, and reported biannually at Pharmacyand Therapeutics Committee meetings and monitors compliance.
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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 Chief of Staff ensures mental health providers consistently document patient or surrogate informed consent and identify the receiving provider when patients are transferred out of the facility and monitors the providers’ compliance.
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9 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
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10 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
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11 The Associate Director ensures the locked mental health unit’s security surveillance television system is included in the annual physical security assessment and is regularly tested and monitors compliance.
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12 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 compliance.
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13 The Facility Director ensures that the use of reversal agents in moderate sedation cases and the presence or absence of adverse events are reported to and trended by the Performance Improvement Committee and monitors compliance.
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14 The Chief of Staff ensures providers perform history and physical exams within 30 days prior to the moderate sedation procedure and include all required elements in the history and physical exams and/or pre-sedation assessments and monitors providers’ compliance.
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15 The Chief of Staff ensures clinical employees who perform, assist with, or supervise moderate sedation procedures have current Basic Life Support certification and moderate sedation training and monitors their compliance.
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| 17-00833-05 | Review of VA's Reimbursements to the Treasury Judgment Fund | Audit | ||
1 We recommended the Acting Assistant Secretary for Management and Acting Chief Financial Officer establish procedures to ensure VA reimburses the Treasury Judgment Fund within 45 business days of receipt of requests for reimbursement or establishes appropriate payment plans for claims paid pursuant to applicable law.
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| 17-00414-376 | Review of Alleged Use of Inappropriate Wait Lists for Group Therapy and Post Traumatic Stress Disorder Clinic Team, Eastern Colorado Health Care System | Audit | ||
1 The OIG recommended the director of the Eastern Colorado Health Care System ensure mental health staff schedule veterans for appointments or add them to the electronic wait lists when acting on care requests.
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2 The OIG recommended the director of the Eastern Colorado Health Care System ensure that Colorado Springs resources are sufficient to process PCT consult requests within seven days of receipt.
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3 The OIG recommended the director of the Eastern Colorado Health Care System ensure that Colorado Springs PCT staff enter the clinically indicated date from the consult when scheduling veterans’ appointments.
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4 The OIG recommended the director of the Eastern Colorado Health Care System ensure that Colorado Springs PCT staff enter consult actions, including scheduling efforts, in the electronic health record.
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| 16-03519-28 | Healthcare Inspection – Mental Health Care Concerns, Atlantic County Community Based Outpatient Clinic, Northfield, New Jersey | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that Atlantic County Community Based Outpatient Clinic schedulers determine and document appointment dates using clinically indicated and desired/preferred dates and
facility managers monitor compliance.
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2 We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process for management of established mental health patients seeking an unscheduled appointment that includes communication between patients and clinical and administrative staff.
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3 We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process including a definition of supervisor responsibilities for oversight and auditing of scheduling and no-shows, and facility managers monitor compliance.
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4 We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement a process to manage patients who still need care when Community Based Outpatient Clinic staff have cancelled appointments, and facility managers monitor compliance.
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5 We recommended that the Veterans Integrated Service Network Director ensure Atlantic County Community Based Outpatient Clinic managers implement the Community Based Outpatient Clinic Mental Health services termination process as outlined in local policy.
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6 We recommended that the Veterans Integrated Service Network Director ensure the Facility Director implements oversight processes that ensure non-VA care coordination staff follow-up on all consults in a timely manner and facility managers monitor
compliance.
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| 17-02811-21 | Audit of VA's Compliance With the DATA Act | Audit | ||
1 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer continue progress with system modernization efforts. Ensure that current and upcoming DATA Act requirements are incorporated so that the detail level requirements for meeting the DATA Act will be made possible as automatic bulk file transmissions going forward.
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2 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer establish milestones to monitor VA's system modernization efforts. Coordination with the shared service provider should continue to incorporate current and upcoming DATA Act requirements to ensure that they will be met going forward.
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3 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer obtain procurement management system and if feasible, grants management system capabilities that are integrated with the financial system as part of VA's transition to a shared service provider.
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4 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer to the extent possible, reduce the amount of journal vouchers to those related to accrual adjustments or one time, unusual Adjusted Trial Balance System (GTAS) trial balance and resolve variances between the two systems. transactions. Journal vouchers recorded should contain data elements required for File B such as the program activity. In addition, if possible, automate efforts to combine FMS journal output files with the MinX-based Governmentwide Treasury Account Symbol
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5 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer reduce the extensive use of 1358 obligations, and develop an automated procurement action capturing and reporting mechanism to timely capture all procurement activities greater than $3,500 for the File D1 submission.
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6 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer prepare the SBR and ensure reconciliation of File A, SF-133s and the SBR prior to File A submission.
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7 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer continue efforts to reduce the number of journal vouchers to those related to accrual adjustments or one time, unusual transactions. Journal vouchers recorded should contain data elements required for File B such as the program activity code and budget object class. In addition, if feasible, automate efforts to combine FMS journal output files with the MinX-based GTAS trial balance and identify and resolve variances between the two systems.
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8 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer where feasible, perform validation of MinX journal vouchers as they may contain errors and reside in the ultimate File B submission.
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9 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer research and resolve warnings identified by the broker before DATA Act files submission.
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10 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure that knowledge of DATA Act processes is not limited to one or a few people, and develop a succession plan to ensure the required expertise and capabilities will continue to remain available before personnel with highly technical and specialized knowledge leave or retire from the agency.
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11 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure complete reconciliations between the subsidiary and general ledger systems are performed. Differences should be researched and resolved to improve data accuracy, completeness and quality.
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12 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer for all TASes, ensure that amounts can be distinguished between general ledger accounts 4901 and 4902.
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13 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure a timely reconciliation process between File A and File B; File B to File C (when applicable); and File B to Files D1 and D2 such that procedures are completed prior to certifying each quarter¿s submission through the broker. Research and resolve variances identified through reconciliation processes.
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14 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer maintain documentation to support the various cost allocation methodologies used for aggregating VHA transactions included in File D2. Ensure File D2 VHA aggregated data includes only the required costs for DATA Act submission. Seek formal confirmation from OMB and Treasury that the direct services VHA is reporting should be included in File D2 as financial assistance awards and the employee payroll and File D1 duplicate contract cost data VHA is reporting should or should not be included in File D2 as financial assistance awards
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15 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer provide targeted training to address specific issues identified to DATA Act points of contact on USASpending.gov requirements.
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16 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer implement PMO oversight of the reports submitted by VBA and VHA's ARC to ensure completeness, timeliness, quality, and accuracy of the information reported.
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17 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer implement internal controls related to the proper tracking and accounting for intragovernmental transfers as to their trading partner, type, and nature. Produce reliable subsidiary reports with transfer level details to facilitate management¿s reconciliation and reporting with the trading partner. Any differences between File A and B should be researched and corrected prior to file submission.
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18 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer research and identify the root cause of those transactions with default program activity names and implement corrective actions to address those issues. In addition, implement FMS and MinX JV edit checks to ensure all JVs contain the proper program activity name, program activity code and object class code or the JV will not be accepted by the system. The JV reviewer should ensure all those elements are properly recorded and are consistent with OMB A-11 and the President's Budget to improve the accuracy of the data.
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19 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer assess the impact of the internal control weaknesses reported and develop corrective actions to address data quality issues at the individual or aggregate transaction level.
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20 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer ensure the complete reporting of all required data elements. Establish and develop a process to validate data quality for all DATA Act files on a regular basis prior to file submission
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21 We recommend the Acting Assistant Secretary for Management and Acting Chief Financial Officer continue to maintain communication with OMB and Treasury regarding VA¿s data reporting limitations and progress, and document such communication.
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| 17-01208-07 | Healthcare Inspection – Patient Death Following Failure to Attempt Resuscitation, VA Ann Arbor Healthcare System, Ann Arbor, Michigan | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires staff to immediately verify resuscitation status without delaying resuscitative efforts.
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2 We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers update the Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation policies to align with one another and include specific processes and responsibilities for determining resuscitation status, including at the time of a Nurse Led Rapid Response.
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3 We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers educate staff on telemetry policy, align clinical practice with policy, educate staff on this policy and practice, and monitor compliance.
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4 We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers obtain an independent external review of this patient’s medical care.
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5 We recommended that the Veterans Integrated Service Network Director ensures that the System Director consider taking appropriate administrative action for all involved clinicians, including consideration of the reporting requirements to applicable state licensing board(s).
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6 We recommended that the Veterans Integrated Service Network Director ensures that the System Director requires that System managers review electronic health record documentation of resident supervision, medical decision-making, and resident physician to attending physician discussion of care during an emergency situation and monitor compliance.
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| 16-00352-12 | Healthcare Inspection – Administrative and Clinical Concerns, Central California VA Health Care System, Fresno, California | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that System leaders establish written protocols to identify a process to transfer Emergency Department boarded patients to available VA and non-VA facilities when acute inpatient beds are unavailable.
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2 We recommended that the Veterans Integrated Service Network Director ensure that the policy that designates the location for Emergency Department patient overflow includes criteria for boarded patients who can be placed in the community living center.
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3 We recommended that the Veterans Integrated Service Network Director ensure that a policy is developed and implemented to ensure that Emergency Department staff offer boarded patients transfer to a VA or non-VA facility for inpatient care and that Emergency Department staff document the offers and managers monitor compliance.
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4 We recommended that the Veterans Integrated Service Network Director ensure that managers continue to strengthen processes to improve boarded patients’ length of stay in the Emergency Department.
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5 We recommended that the Veterans Integrated Service Network Director ensure that Emergency Department providers reassess patients prior to transfer to confirm that patients are stabilized and suitable for transfer to the receiving unit.
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6 We recommended that the Veterans Integrated Service Network Director implement applicable recommendations from previous patient event-related reviews and monitor compliance.
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7 We recommended that the Veterans Integrated Service Network Director consult with the Office of Chief Counsel regarding whether an institutional disclosure might be appropriate.
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8 We recommended that the Veterans Integrated Service Network Director consider requesting an external administrative review to determine whether the system was adequately prepared to safely manage its patient volume.
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| 16-02676-13 | Healthcare Inspection – Evaluation of System-Wide Clinical, Supervisory, and Administrative Practices, Oklahoma City VA Health Care System, Oklahoma City, Oklahoma | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director review the former Chief of Surgery’s performance in relation to issues discussed in this report, and confer with appropriate VA offices to determine the need for administrative action, if any.
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2 We recommended the System Director consult with the National Center for Organizational Development to facilitate organizational improvement following leadership changes and extensive inspections and investigations.
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3 We recommended that the System Director ensure use of the correct methodology to determine the severity assessment code for all reported patient safety events.
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4 We recommended that the System Director ensure compliance with the National Center for Patient Safety’s guidelines on initiation and completion of Root Cause Analysis.
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5 We recommended that the System Director ensure that peer reviews are appropriately completed and address all relevant aspects of care provided by the reviewed clinician.
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6 We recommended that the System Director ensure a process is in place to identify and review cases where institutional disclosure may be indicated, and complete as appropriate.
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7 We recommended the System Director ensure that the Quality, Safety and Value committee minutes include evidence of robust data analysis and action tracking to address performance deficiencies, and monitor for compliance.
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8 We recommended that the System Director ensure adherence to all Veterans Health Administration peer review committee requirements, and monitor for compliance.
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9 We recommended that the System Director ensure that professional practice evaluations include performance data to support provider privileges and are conducted in accordance with Veterans Health Administration and System policy.
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10 We recommended that the System Director evaluate the current System policy and services provided by low volume/no volume providers to determine whether the System should continue to provide those services or seek community alternatives.
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11 We recommended that the System Director require service chiefs to assure that all providers within their purview secure and maintain appropriate computer access to ensure quality and continuity of patient care.
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12 We recommended that the System Director ensure availability of functional equipment, adequate staffing, and enhanced access for personal identity verification card completion.
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13 We recommended that the System Director ensure compliance in monitoring of resident supervision documentation in accordance with Veterans Health Administration and System policies, and take appropriate action when deficiencies are identified.
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14 We recommended that the System Director review letters of agreement between the University of Oklahoma’s surgical residency program and the System to ensure compliance with Accreditation Council for Graduate Medical Education requirements.
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15 We recommended that the System Director continue efforts to recruit and hire for vacancies, and ensure that, until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
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16 We recommended that the System Director ensure timely completion of specialty care consults and monitor compliance.
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17 We recommended that the System Director implement a process to conduct routine scheduling audits to monitor compliance and identify ongoing training opportunities for all schedulers.
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18 We recommended that the System Director conduct an evaluation of the potential improper payments resulting from clinic cancellations, take appropriate corrective actions, and establish policies to mitigate improper payments related to clinic cancellations from occurring in the future.
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19 We recommended that the System Director continue efforts to improve call center timeliness.
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20 We recommended that the System Director continue efforts to improve timeliness of Care in the Community Program consult completion; enhance patient and community provider understanding of Veterans Choice and Non-VA Care Coordination options; and continue to promote communication and coordination with TriWest Healthcare Alliance to assure appropriate, timely care for patients.
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21 We recommended that the System Director ensure Patient Aligned Care Team clinicians follow Veteran Health Administration requirements for patient notification and follow-up of clinically relevant abnormal laboratory results and document the actions in the electronic health record.
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22 We recommended that the System Director monitor consultation completion timeliness and identify process improvements for consults exceeding 30 days.
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23 We recommended that the System Director continue Emergency Department workgroup efforts to improve the timeliness of care, decrease the frequency of diversion status, and enhance customer service in the Emergency Department.
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24 We recommended that the System Director ensure that all patient care areas comply with environment of care requirements and that action plans specifically address deficient areas identified in this report.
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14957