Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-03822-359 | Healthcare Inspection – Alleged Provision of Care, Nursing Supervision, and Scheduling Issues at Community Based Outpatient Clinics at the Amarillo VA Health Care System, Amarillo, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Amarillo VA Health Care System Director ensure that community based outpatient clinics are appropriately staffed to provide care.
Closure Date:
2 We recommended that the Amarillo VA Health Care System Director ensure that managers conduct clinical reviews of the three Clovis Community Based Outpatient Clinic patients discussed in this report to determine whether a delay in follow-up adversely affected their outcomes and take action as appropriate.
Closure Date:
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| 15-03288-362 | Healthcare Inspection—Inconsistent Transfer Procedures for Urgent Care Clinic Patients with Stroke Symptoms, Manchester VA Medical Center, Manchester, New Hampshire | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Urgent Care Clinic providers consistently transfer stroke patients to an appropriate acute care facility in accordance with Veterans Health Administration and facility policies and procedures.
Closure Date:
2 We recommended that the Facility Director ensure that the Peer Review Committee follows Veterans Health Administration policy.
Closure Date:
3 We recommended that the Facility Director ensure that facility managers clinically review the records of the 13 patients not transferred to the non-VA acute care hospital, approximately 2.5 miles away, to determine whether patient harm occurred and take action as appropriate.
Closure Date:
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| 16-00552-341 | Clinical Assessment Program Review of the Michael E. DeBakey VA Medical Center, Houston, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility managers ensure floors and rolling equipment in patient care areas are clean and in good repair and monitor compliance.
Closure Date:
3 We recommended that the facility review quality assurance data for the anticoagulation management program monthly at Pharmacy and Therapeutics Committee meetings and that facility managers monitor compliance.
Closure Date:
4 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulants.
Closure Date:
5 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments 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 that facility managers monitor compliance.
Closure Date:
6 We recommended that the laboratory director develop and implement a process to ensure employee competency for point-of-care testing with glucometers.
Closure Date:
7 We recommended that the laboratory director ensure employees who perform glucose testing at the point of care have annual competencies for glucometers and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
Closure Date:
9 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
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10 We recommended that facility managers ensure social workers and registered nurses conduct and document cyclical visits with the frequency required by Veterans Health Administration policy for community nursing home oversight and monitor compliance.
Closure Date:
11 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
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12 We recommended that facility managers ensure all employees receive Level 1 Prevention and Management of Disruptive Behavior training and additional training as required for their assigned risk area within 90 days of hire and that the training is documented in employee training records.
Closure Date:
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| 17-00970-327 | Inspection of VA Regional Office Wilmington, Delaware | Review | ||
1 We recommended the Wilmington VA Regional Office Director implement a plan to assess the effectiveness of second-signature reviews for Special Monthly Compensation and Ancillary Benefits claims.
Closure Date:
2 We recommended the Wilmington VA Regional Office Director implement plans to ensure the effectiveness of training conducted on processing claims for higher-level Special Monthly Compensation and Ancillary Benefits.
Closure Date:
3 We recommended that the Wilmington VA Regional Office Director implement a plan to ensure management provides a consistent quality review process which addresses all elements required when establishing claims in the electronic record and monitor the effectiveness of that plan.
Closure Date:
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| 17-01354-336 | Inspection of Denver VA Regional Office | Review | ||
1 We recommended the Denver VA Regional Director implement a plan to complete proposed rating reduction cases at the end of the due process period.
Closure Date:
2 We recommended that the Denver VA Regional Office Director implement a plan to ensure all claims processing staff receive formal training on claims establishment procedures and monitor the effectiveness of that training.
Closure Date:
3 We recommended the Denver VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is reviewed for accuracy.
Closure Date:
4 We recommended the Denver VA Regional Office Director implement a plan to update the checklist used to evaluate quality at the time of claims establishment.
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| 16-02526-358 | Healthcare Inspection – Physical Medicine and Rehabilitation Services Consult Process Concerns, Central Texas Veterans Health Care System, Temple, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that consult clinical reviews and appointment scheduling for patients are conducted in compliance with Veterans Health Administration directives and system policies.
Closure Date:
2 We recommended that Physical Medicine and Rehabilitation Services have sufficient staffing to arrange for timely consultations and appointments within the service.
Closure Date:
3 We recommended that the Facility staff who schedule Physical Medicine and Rehabilitation Services patient appointments receive annual scheduling competencies to ensure understanding of the correct process for compliance with Veterans Health Administration directives and staff are monitored for compliance.
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| 15-00650-353 | Healthcare Inspection – Delays in Scheduling Diagnostic Studies and Other Quality of Care Concerns, William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that outpatient echocardiography and stress test consult requests are scheduled and completed in accordance with Veterans Health Administration policy.
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2 We recommended that the Facility Director ensure that sleep study consult requests are scheduled and completed within the timeframe required by Veterans Health Administration policy.
Closure Date:
3 We recommended that the Facility Director ensure that patients’ cardiac diagnostic and procedure reports are signed within the timeframe specified by policy to ensure appropriate follow-up and patient care coordination.
Closure Date:
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| 17-01276-300 | Inspection of the VA Regional Office Philadelphia, Pennsylvania | Review | ||
1 We recommended the Philadelphia VA Regional Office Director develop and implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
Closure Date:
2 We recommended the Philadelphia VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.
Closure Date:
3 We recommended the Philadelphia VA Regional Office Director implement a plan to assess the effectiveness of the most recent claims establishment training.
Closure Date:
4 We recommended the Philadelphia VA Regional Office Director provide training on special controlled correspondence to ensure accurate and complete responses to the veteran and Congressional staff, and monitor the effectiveness of the training.
Closure Date:
5 We recommended the Philadelphia VA Regional Office Director improve oversight of special controlled correspondence.
Closure Date:
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| 17-00394-298 | Inspection of the VA Regional Office Louisville, Kentucky | Audit | ||
1 We recommended the Louisville VA Regional Office Director assess the effectiveness of the most recent refresher training for higher level special monthly compensation.
Closure Date:
2 We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight and assess the accuracy of secondary reviews involving higher-level special monthly compensation and ancillary benefits.
Closure Date:
3 We recommended the Louisville VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the expiration of the due process time period.
Closure Date:
4 We recommended the Louisville VA Regional Office Director implement a plan to conduct training that emphasizes date of claim policies and accurate contention classifications, and to monitor the effectiveness of the training.
Closure Date:
5 We recommended the Louisville VA Regional Office Director implement a plan to strengthen oversight for newly hired staff who establish claims.
Closure Date:
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| 15-03418-350 | Healthcare Inspection: Patient Flow, Quality of Care, and Administrative Concerns in the Emergency Department, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers strengthen patient flow processes.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure that VA Maryland Health Care System managers evaluate staff's Emergency Department Integrated Software data entry and implement action plans to ensure data accuracy and timeliness.
Closure Date:
3 We recommended that the Veterans Integrated Service Network Director ensure that the VA Maryland Health Care System managers strengthen Patient Flow Committee processes to include the establishment of patient flow goals, action target dates, and oversight of action implementation.
Closure Date:
4 We recommended that the System Director ensure that policy regarding patients boarding in the Emergency Department include all required elements.
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5 We recommended that the System Director strengthen Bed Management Solution utilization and processes, and monitor compliance.
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6 We recommended that the System Director strengthen processes to improve timeliness of bed cleaning.
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7 We recommended that the System Director review the impact of inpatient medicine admission capping and establish alternative plans that improve patient flow from the Emergency Department, monitor outcomes, and implement alternative plans as warranted.
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8 We recommended that the System Director review and address processes that contribute to delays of inpatient discharge.
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9 We recommended that the System Director strengthen nursing service communication processes to ensure consistent inpatient care coverage and nurses' availability for Emergency Department handoff.
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10 We recommended that the System Director evaluate the adequacy of Emergency Department administrative support staffing and take appropriate action.
Closure Date:
11 We recommended that the System Director improve and monitor compliance with response time requirements for after-hour computerized tomography scan services.
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14957