Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01850-38 | Comprehensive Healthcare Inspection Program Review of the VA Eastern Kansas Health Care System, Topeka, Kansas | 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 Chief of Staff ensures clinicians consistently provide specific education to all patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
4 The Assistant Director ensures all 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:
5 The Chief of Staff and Associate Director for Patient Care Services ensure 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 their compliance.
Closure Date:
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| 17-01752-32 | Comprehensive Healthcare Inspection Program Review of the Bath VA Medical Center, Bath, New York | 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 that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
Closure Date:
3 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ compliance.
Closure Date:
4 The Associate Director ensures all areas of the facility are inspected at the required frequency and monitors compliance.
Closure Date:
5 The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
Closure Date:
6 The Associate Director ensures that an inventory of the required number of filled oxygen tanks is maintained at the Wellsboro VA Clinic and monitors compliance.
Closure Date:
7 The Associate Director ensures that an adequate supply of personal protective equipment (masks, gloves, gowns, and goggles) is available for employees at the Wellsboro VA Clinic and monitors compliance.
Closure Date:
8 The Associate Director ensures that clean and sterile supplies are stored on supply room carts that have solid bottom shelves at the Wellsboro VA Clinic and monitors compliance.
Closure Date:
9 The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program employees conduct and document monthly self-inspections, weekly contraband inspections, every 2-hour rounds of all public spaces, and daily resident room inspections for unsecured medications and monitors employees’ compliance.
Closure Date:
10 The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program managers ensure the main point of entry has a keyless system and monitors compliance.
Closure Date:
11 The Chief of Staff ensures that Domiciliary Residential Rehabilitation Treatment Program managers ensure all non-main entrance doors are locked to prevent unauthorized entry and alarmed at all times and monitors compliance.
Closure Date:
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| 15-03364-380 | Audit of VHA’s Management of Primary Care Panels | Audit | ||
1 The OIG recommended the Acting Under Secretary for Health establish standardized primary care scheduling processes that provide newly enrolled veterans an opportunity to schedule an appointment at the time of enrollment.
Closure Date:
2 The OIG recommended the Acting Under Secretary for Health establish metrics to monitor the time it takes facilities to offer scheduling for an initial primary care appointment, beginning with the date the veteran submits a completed enrollment form.
Closure Date:
3 The OIG recommended the Acting Under Secretary for Health improve oversight by ensuring facilities set panel sizes consistent with VHA’s recommended model panel sizes, submit written justification for panel sizes that deviate from VHA’s model panel sizes for review and approval by VHA, or implement corrective action to mandate appropriate panel size.
Closure Date:
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| 17-00397-364 | Review of Alleged Appeals Data Manipulation at the VA Regional Office, Roanoke, Virginia | Audit | ||
1 The OIG recommended the Roanoke VA Regional Office Director conduct a review to identify prematurely closed appeals records, confer with appropriate VBA officials to determine the proper corrective actions to take, if any, and provide certification of completion of the review to the Office of Inspector General.
Closure Date:
2 The OIG recommended the Roanoke VA Regional Office Director confer with Regional Counsel to determine what steps to take, if any, with regard to management or staff involved in the conduct discussed in this report.
Closure Date:
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| 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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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
Closure Date:
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
Closure Date:
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.
Closure Date:
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.
Closure Date:
7 The Chief of Staff ensures that facility managers conduct annual infection prevention risk assessments.
Closure Date:
8 The Assistant Director ensures that dirty and used equipment is stored separately from sterile supplies.
Closure Date:
9 The Assistant Director ensures that staff regularly test panic alarms at the Santa Ana Outpatient Primary Care Clinic.
Closure Date:
10 The Assistant Director ensures that staff regularly test camera surveillance equipment on the locked mental health unit and monitors compliance.
Closure Date:
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.
Closure Date:
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.
Closure Date:
13 The Facility Director ensures that the community nursing home program is integrated into the facility quality improvement program.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
2 The Chief of Staff ensures clinical managers consistently review Ongoing Professional Practice Evaluation data twice per year and monitors the managers’ compliance.
Closure Date:
3 The Facility Director ensures clinical managers complete at least 75 percent of allrequired inpatient utilization management reviews and monitors the managers’compliance.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
7 The Facility Director ensures inter-facility patient transfer data are analyzed and reported to an identified quality oversight committee assigned these responsibilities and monitors compliance.
Closure Date:
8 The 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.
Closure Date:
9 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
10 The Associate Director ensures locked mental health unit panic alarm testing documentation includes VA Police response time and monitors compliance.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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15039