Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-02156-346 | Healthcare Inspection–Review of Opioid Prescribing Practices, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director convene an expert panel knowledgeable in the subspecialties of Pain Medicine and Addiction Medicine to review the subject provider’s opioid prescribing practices within the context of the patients whose treatment varied from guidelines as described in this report, ensure that the expert panel expand the review as necessary, and submit a report of findings to the Veterans Integrated Service Network and Facility Directors.
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2 We recommended that the Veterans Integrated Service Network Director ensure the monitoring patients on Suboxone.
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3 We recommended that the Veterans Integrated Service Network Director ensure the Pain Committee strengthens processes to improve communication with the facility to ensure information is relayed timely.
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4 We recommended that the Facility Director ensure that providers access the Prescription Drug Monitoring Program database as required by facility policy and monitor compliance.
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5 We recommended that the Facility Director ensure adequate resources, such as additional staff or allotted duty time, are allocated for patient reviews for opioid therapy appropriateness.
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| 17-00515-299 | Inspection of the VA Regional Office Phoenix, Arizona | Review | ||
1 We recommended the Phoenix VA Regional Office Director implement a plan to ensure Rating Veterans Service Representatives follow second signature policy requirements for special monthly compensation rating decisions and perform an effective review.
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2 We recommended the Phoenix VA Regional Office Director implement a plan to improve the second signature review process for special monthly compensation rating decisions.
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3 We recommended the Phoenix VA Regional Director implement a plan to prioritize proposed rating reduction cases for completion at the end of the due process time period.
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4 We recommended the Phoenix VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is accurate.
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5 We recommended the Phoenix 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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6 We recommended the Phoenix VA Regional Office Director provide training to congressional liaisons on special controlled correspondence to ensure all documents are included in the electronic record in accordance with current Veterans Benefits Administration guidance.
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7 We recommended the Phoenix VA Regional Office Director update the office’s local procedures relating to special controlled correspondence in accordance with current Veterans Benefits Administration procedures.
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| 16-02998-345 | Healthcare Inspection – Pressure Ulcer Prevention and Management, VA New York Harbor Healthcare System, New York, New York | Hotline Healthcare Inspection | ||
1 We recommended that the VA New York Harbor Healthcare System Director consult with the Office of Chief Counsel regarding possible institutional disclosure to Patient A’s family.
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2 We recommended that the VA New York Harbor Healthcare System Director ensure that processes are developed to track whether and when orders for pressure-reducing mattresses or overlays are satisfied.
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3 We recommended that the VA New York Harbor Healthcare System Director ensure that staff have the capability to order and receive pressure-reducing mattresses and overlays for patients during “off tour” hours, including nights, weekends, and holidays.
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4 We recommended that the VA New York Harbor Healthcare System Director ensure that pressure ulcer-related documentation adheres to VHA policy.
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5 We recommended that the VA New York Harbor Healthcare System Director consider the appropriateness of updating the nursing discharge documentation to prompt staff to complete skin assessments proximal to the time of discharge.
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| 16-00597-279 | Audit of VHA's Imaging Service Scheduling Practices in the South Texas Veterans Health Care System | Audit | ||
1 We recommended the South Texas Veterans Health Care System Director require staff to review all pending orders that are past due to identify those orders which are active and those which need to be canceled because they have been completed or are no longer needed.
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2 We recommended the South Texas Veterans Health Care System Director develop a plan to address any pending exams that are past due to ensure patients who have experienced significant delays receive needed exams.
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3 We recommended the South Texas Veterans Health Care System Director ensure staff review the health care system’s current hard copy scheduling process to reduce inefficiencies related to duplicate orders, inaccurate record keeping, and the inventory of pending orders.
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4 We recommended the South Texas Veterans Health Care System Director ensure Imaging Service staff implement VHA’s Outpatient Radiology Scheduling Policy and Procedures and establish monitoring mechanisms where staff review pending orders at designated intervals and remove duplicate exams to facilitate the timely completion of exams.
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5 We recommended the South Texas Veterans Health Care System Director implement a program to educate and remind clinicians of the processes they should use to avoid the creation of unnecessary duplicate orders.
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| 17-00602-342 | Healthcare Inspection – Quality of Care Concerns in Thoracic Surgery, Bay Pines VA Healthcare System, Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that focused professional practice evaluations review criteria are sufficient to evaluate the privilege-specific competence for thoracic surgeons.
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2 We recommended that the System Director ensure that ongoing professional practice evaluation reviews are conducted by providers with training and privileges similar to those of the provider under review.
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| 16-00577-335 | Clinical Assessment Program Review of the VA Northern Indiana Health Care System, Fort Wayne, Indiana | 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.
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2 We recommended that facility managers ensure clean bed frames in patient care areas and monitor compliance.
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3 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
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4 We recommended that the facility designate a physician anticoagulation program champion.
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5 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
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6 We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
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7 We recommended that the facility collect and report data on patient transfers out of the facility.
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8 We recommended that for patients transferred out of the facility, providers consistently include date of transfer, documentation of patient or surrogate informed consent, documentation of medical and behavioral stability, and identification of transferring and receiving provider or designee in transfer documentation and that facility managers monitor compliance.
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9 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
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10 We recommended that for patients transferred out of the facility, employees enter a progress note titled, “Inter-facility Transfer Notes for Individual Disciplines.”
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11 We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
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12 We recommended that facility managers 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 that facility managers monitor compliance.
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13 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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14 We recommended that the facility’s Disruptive Behavior Committee include a senior clinician chair and the Patient Safety Manager and/or Risk Manager and that the Patient Advocate consistently attend Disruptive Behavior Committee meetings.
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15 We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
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16 We recommended that facility clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
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17 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.
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18 We recommended that that the Medical Executive Committee discuss and document its approval of the use of another facility’s physicians for teledermatology services.
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19 We recommended that the facility obtain teledermatology physicians’ professional practice evaluation information from the providing facility.
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| 16-00555-337 | Clinical Assessment Program Review of the James E. Van Zandt VA Medical Center, Altoona, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility consistently take action when data analyses indicated problems or opportunities for improvement and evaluate the actions for effectiveness in peer review and Focused Professional Practice Evaluations and that facility managers monitor compliance.
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2 We recommended that the facility Chief of Staff ensure that all required practitioners are designated as members of the medical staff.
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3 We recommended that facility managers ensure the access log for the Huntingdon County VA Clinic information technology network room includes all required elements to document access and that facility managers monitor compliance.
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4 We recommended that facility managers implement a process to protect personally identifiable information on laboratory specimens at the Huntingdon County VA Clinic and that facility managers monitor compliance.
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5 We recommended that the facility designate a physician anticoagulation program champion.
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6 We recommended that the facility collect and report data on patient transfers out of the facility.
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7 We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
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8 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
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9 We recommended that facility managers ensure integration of the community nursing home program into its quality improvement program.
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10 We recommended that facility managers 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 that facility managers monitor compliance.
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11 We recommended that a VA physician order or approve all therapies that are at VA expense.
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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 training is documented in employee training records.
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| 16-00355-296 | Audit of the VHA's Health Care Enrollment Program at Medical Facilities | Audit | ||
1 We recommended the Acting Under Secretary for Health develop standardized national policy and procedures for the health care enrollment program at VA medical facilities.
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2 We recommended the Acting Under Secretary for Health implement national oversight of the health care enrollment program to continually review operations and performance of VHA medical facilities.
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3 We recommended the Acting Under Secretary for Health provide mandatory and standardized training on eligibility and enrollment to ensure health care applications are processed accurately and timely.
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4 We recommended the Acting Under Secretary for Health develop and execute a process to distinguish new applications for health care enrollment in VistA from other registration data.
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5 We recommended the Acting Under Secretary for Health implement a plan to correct current data integrity issues in VistA to improve the accuracy and timeliness of enrollment data.
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| 16-05468-282 | Inspection of the VA Regional Office Atlanta, Georgia | Review | ||
1 We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases are appropriately distributed to the most qualifiedpersonnel.
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2 We recommended the Atlanta VA Regional Office Director implement aplan to monitor the effectiveness of training on higher-level SpecialMonthly Compensation and Ancillary Benefits.
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3 We recommended the Atlanta VA Regional Office Director implement aplan to ensure higher-level Special Monthly Compensation and AncillaryBenefits cases receive an accurate, signed second-level review.
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4 We recommended the Southeast District Director implement a plan toensure the Atlanta VA Regional Office Director provides oversight andprioritization of proposed rating reductions claims for completion at theend of the due process period.
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5 We recommended that the Atlanta VA Regional Office Director ensureclaims assistants receive all systems compliance related training relevantto claims establishment.
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6 We recommended that the Atlanta VA Regional Office Directorimplement a plan to modify the quality review checklist on claimsestablishment to include claim label and claimed issue classification indicators for all claims.
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7 We recommended the Atlanta VA Regional Office Director implement aplan to ensure claims processing staff properly establish and maintainend product 500s for control of special controlled correspondence.
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8 We recommended the Atlanta VA Regional Office Director implement aplan to ensure staff adhere to Veterans Benefits Administration policyand acknowledge special controlled correspondence with a timely interimor full response.
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| 16-04626-280 | Inspection of the VA Regional Office, New Orleans, Louisiana | Review | ||
1 We recommended the New Orleans VA Regional Office Directorimplement a plan to assess the effectiveness of secondary reviews forSpecial Monthly Compensation and ancillary benefits claims.
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2 We recommended the Continental District Director implement a plan toensure oversight and prioritization of proposed rating reduction cases forcompletion at the end of the due process time period at the New OrleansVA Regional Office.
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3 We recommended the New Orleans VA Regional Office Director ensureclaims assistants receive all mandatory annual training on claimsestablishment procedures.
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4 We recommended the New Orleans VA Regional Office Directorimplement a plan to strengthen the review process to assess all elementsrequired when establishing claims in the electronic record.
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5 We recommended the New Orleans VA Regional Office Directorprovide training to Legal Administrative Specialists responsible forprocessing controlled correspondence and monitor the effectiveness ofthe training.
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6 We recommended the New Orleans VA Regional Office Director ensureLegal Administrative Specialists adhere to Veterans Benefits Administration policy when processing special controlled correspondence.
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14957