Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
Closure Date:
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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| 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.
Closure Date:
5 We recommended that the System Director strengthen Bed Management Solution utilization and processes, and monitor compliance.
Closure Date:
6 We recommended that the System Director strengthen processes to improve timeliness of bed cleaning.
Closure Date:
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.
Closure Date:
8 We recommended that the System Director review and address processes that contribute to delays of inpatient discharge.
Closure Date:
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.
Closure Date:
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.
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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| 15-02156-346 | 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.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure the monitoring patients on Suboxone.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
4 We recommended the Phoenix VA Regional Office Director implement a plan to ensure data input at the time of claims establishment is accurate.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
4 We recommended that the VA New York Harbor Healthcare System Director ensure that pressure ulcer-related documentation adheres to VHA policy.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
2 We recommended that facility managers ensure clean bed frames in patient care areas and monitor compliance.
Closure Date:
3 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
Closure Date:
4 We recommended that the facility designate a physician anticoagulation program champion.
Closure Date:
5 We recommended that facility managers ensure clinicians consistently obtain all required laboratory tests prior to initiating anticoagulant medications.
Closure Date:
6 We recommended that for employees actively involved in the anticoagulant program, clinical managers complete competency assessments annually and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
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.
Closure Date:
9 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
Closure Date:
10 We recommended that for patients transferred out of the facility, employees enter a progress note titled, “Inter-facility Transfer Notes for Individual Disciplines.”
Closure Date:
11 We recommended that providers re-evaluate patients immediately before moderate sedation for changes since the prior assessment and that facility managers monitor compliance.
Closure Date:
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.
Closure Date:
13 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
Closure Date:
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.
Closure Date:
15 We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
19 We recommended that the facility obtain teledermatology physicians’ professional practice evaluation information from the providing facility.
Closure Date:
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15039