Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-04918-263 | Inspection of the VA Regional Office Indianapolis, Indiana | Review | ||
1 We recommended the Indianapolis VA Regional Office Director ensure and implement local training that complies with Veterans Benefits Administration policy and implement plans to ensure the effectiveness of that training for evaluation of higher-level Special Monthly Compensation claim and ancillary benefits.
Closure Date:
2 We recommended the Midwest District Director implement a plan to ensure the Indianapolis VA Regional Office Director provides oversight and prioritization of proposed rating reduction cases for completion at the end of the due process time period.
Closure Date:
3 We recommended that the Indianapolis VA Regional Office Director provide training to Claims Assistant on how to assign the correct medical classification to claimed disabilities and monitor the effectiveness of that training.
Closure Date:
4 We recommended that the Indianapolis VA Regional Office Director implement a plan to modify the quality review checklist on claims establishment to include “claimed issue with classification” and “special issue” indicators for all claims.
Closure Date:
5 We recommended the Indianapolis VA Regional Office Director implement a plan to comply with Veteran Benefits Administration policy for managing and processing special controlled correspondence.
Closure Date:
6 We recommended the Indianapolis VA Regional Office Director provide training to the Congressional Liaison responsible for processing special controlled correspondence.
Closure Date:
7 We recommended the Indianapolis VA Regional Office Director develop and implement a plan to assess the effectiveness of the special controlled correspondence checklist.
Closure Date:
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| 16-04764-266 | Inspection of the VA Regional Office Seattle, Washington | Review | ||
1 We recommended the Seattle VA Regional Office Director implement a plan to ensure traumatic brain injury claims are assigned to qualified Rating Veterans Service Representatives for processing.
Closure Date:
2 We recommended the Seattle VA Regional Office Director implement a plan to provide refresher training on traumatic brain injury and monitor the effectiveness of that training.
Closure Date:
3 We recommended the Seattle VA Regional Office Director implement a plan to ensure Rating Veterans Service Representatives follow second signature policy requirements for traumatic brain injury and special monthly compensation rating decisions.
Closure Date:
4 We recommended the Seattle VA Regional Office Director develop and implement a plan to provide refresher training to Rating Veterans Service Representatives regarding proper procedure for applying effective dates.
Closure Date:
5 We recommended the Seattle VA Regional Office Director implement a plan to ensure prioritization of proposed rating reduction cases for completion at the end of the due process time period.
Closure Date:
6 We recommended the Seattle VA Regional Office Director implement a plan to conduct comprehensive training for claims establishment staff that emphasizes the importance of ensuring all elements are considered when establishing claims, and assess the effectiveness of that training.
Closure Date:
7 We recommended the Seattle VA Regional Office Director implement a plan to ensure data input at the time of claims establishment are reviewed.
Closure Date:
8 We recommended the Seattle VA Regional Office Director monitor the effectiveness of the training regarding how to properly upload emails into electronic claims folders, and conduct refresher training as necessary.
Closure Date:
9 We recommended the Seattle VA Regional Office Director implement a training plan to ensure all status updates on inquiries are made part of the electronic records, and monitor the effectiveness of that training.
Closure Date:
10 We recommended the Seattle VA Regional Office Director implement a plan to provide oversight and quality review of all types of special controlled correspondence.
Closure Date:
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| 16-04535-329 | Healthcare Inspection – Alleged Inadequate Mental Health Care, Iowa City VA Health Care System, Iowa City, Iowa | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Under Secretary for Health ensure that facility staff conduct thorough post suicide reviews to include all information that provides valuable context and details related to the event.
Closure Date:
2 We recommended that the System Director ensure that the system No-Show policy and practice for mental health patients is in alignment with the expectations of the Office of Mental Health Operations and that system leaders monitor compliance.
Closure Date:
3 We recommended that the System Director ensure that clinicians update outpatient mental health treatment plans according to applicable requirements and guidance and that system leaders monitor compliance.
Closure Date:
4 We recommended that the System Director ensure that the Mental Health Treatment Coordinator program complies with VHA requirements and guidance, and that system leaders monitor compliance.
Closure Date:
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| 15-04374-313 | Administrative Investigation - Improper Approval and Use of Leave, VA Medical Center, Chillicothe, Ohio | Administrative Investigation | ||
1 We recommend the Network Director confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Ms. Hepker.
Closure Date:
2 We recommend the Network Director confer with the Offices of Human Resources and General Counsel to review Dr. Johnston’s improper use of sick leave, and consider whether VA should seek recoupment or waive the improper pay and allowances in accordance with VA Financial Policies and Procedures § 010508.
Closure Date:
3 We recommend the Network Director confer with Ms. Hepker to review and revise the local VAMC leave policy, Policy Memorandum No. 05-01 (Leave Administration), to ensure it is consistent with VA’s policy, VA Handbook 5011, limiting the approval of LWOP to employee’s who are reasonably expected to return to duty.
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| 16-00576-310 | Clinical Assessment Program Review of the W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina | 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 all health care occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
Closure Date:
3 We recommended that facility managers ensure air conditioner and steam/heat ventilation grills in the Emergency Department are clean and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure refrigerators in patient nourishment kitchens do not contain unlabeled food items and monitor compliance.
Closure Date:
5 We recommended that the facility implement a policy for cleaning, disinfecting, and sterilizing reusable medical equipment.
Closure Date:
6 We recommended that facility managers ensure standard operating procedures for the colonoscope, esophagogastroduodenoscope, and duodenoscope are consistent with the manufacturers' instructions for use.
Closure Date:
7 We recommended that hemodialysis unit employees secure chemicals when not in use and that the hemodialysis unit manager monitors compliance.
Closure Date:
8 We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
Closure Date:
9 We recommended that providers consistently complete VA form 10-2649A or use a properly templated inter-facility transfer note template for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
10 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, identification of transferring and receiving provider or designee, and details of the reason for transfer or proposed level of care needed in VA Form 10-2649A, Inter-Facility Transfer Form, and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers ensure transfer notes written by acceptable designees document staff/attending physician approval and include a staff/attending physician countersignature and monitor compliance.
Closure Date:
12 We recommended that sending nurses document transfer assessments/notes for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
13 We recommended that facility managers ensure that for emergent transfers, provider transfer notes include a statement of patient stability for transfer and that facility managers monitor compliance.
Closure Date:
14 We recommended that employees perform quality control on glucometers in accordance with the facility's policy/standard operating procedure and the manufacturer's recommendations and that facility managers monitor compliance.
Closure Date:
15 We recommended that providers include history of previous adverse experience with sedation and anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
Closure Date:
16 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:
17 We recommended that providers notify patients of changes in who is performing the moderate sedation procedure and document this in the electronic health record and that facility managers monitor compliance.
Closure Date:
18 We recommended that clinical employees discharge outpatients from the recovery area with orders given by a qualified provider or according to criteria approved by moderate sedation clinical leaders and that clinical managers monitor compliance.
Closure Date:
19 We recommended that the facility integrate the community nursing home program into its quality improvement program.
Closure Date:
20 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 monitor compliance.
Closure Date:
21 We recommended that facility managers ensure Disruptive Behavior Committee discussion of patients' disruptive or violent behavior and entry of a progress note into the patients' electronic health records.
Closure Date:
22 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:
23 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, ensure training is documented in employee training records, and monitor compliance.
Closure Date:
24 We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document monthly self-inspections and that program managers monitor compliance.
Closure Date:
25 We recommended that Substance Abuse Residential Rehabilitation Treatment Program employees conduct and document every 2-hour rounds of all public spaces, daily bed checks, and daily resident room inspections for unsecured medications and that program managers monitor compliance.
Closure Date:
26 We recommended that facility managers ensure the Substance Abuse Residential Rehabilitation Treatment Program unit's non-main entry door is alarmed at all times and that program managers monitor compliance.
Closure Date:
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| 15-01119-315 | Administrative Investigation - Failure to Follow VA Policy, VA Medical Center, Washington, DC | Administrative Investigation | ||
1 We recommend that the Deputy Under Secretary for Health for Operations and Management confer with the Offices of Human Resources and General Counsel to determine the appropriate administrative action to take, if any, against Mr. Hawkins.
Closure Date:
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| 17-01846-316 | Healthcare Inspection - Opioid Prescribing to High-Risk Veterans Receiving VA Purchased Care | National Healthcare Review | ||
1 We recommended that the Acting Under Secretary for Health require that all participating VA purchased care providers receive and review the evidence-based guidelines outlined in the Opioid Safety Initiative.
Closure Date:
2 We recommended that the Acting Under Secretary for Health implement a process to ensure all purchased care consults for non-VA care include a complete up-to-date list of medications and medical history until a more permanent electronic record sharing solution can be implemented.
Closure Date:
3 We recommended that the Acting Under Secretary for Health require non-VA providers to submit opioid prescriptions directly to a VA pharmacy for dispensing and recording of the prescriptions in the patient’s VA electronic health record.
Closure Date:
4 We recommended that the Acting Under Secretary for Health ensure that if facility leaders determine that a non-VA provider’s opioid prescribing practices are in conflict with Opioid Safety Initiative guidelines, immediate action is taken to ensure the safety of all veterans receiving care from the non-VA provider.
Closure Date:
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| 17-00962-262 | Inspection of the Veterans Service Center Cheyenne, Wyoming | Review | ||
1 We recommended that the Denver VA Regional Office Director ensure that the Cheyenne Veterans Service Center implement a plan to ensure that all claims processing staff receive training regarding the proper procedures for inputting dates of claim for system generated reminder notifications.
Closure Date:
2 We recommended that the Denver VA Regional Office Director ensure that the Cheyenne Veterans Service Center implement a plan to perform monthly quality reviews of all employees who establish claims.
Closure Date:
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| 16-00579-293 | Clinical Assessment Program Review of the VA Loma Linda Healthcare System, Loma Linda, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, corrective actions taken to address identified deficiencies, and tracking of corrective actions to closure.
Closure Date:
2 We recommended that the facility implement actions to address all high-risk areas and ensure Infection Control Committee minutes document those actions and the follow-up on actions implemented to address identified problems.
Closure Date:
3 We recommended that facility managers ensure information technology network rooms have logs for visitors to document their access and monitor compliance.
Closure Date:
4 We recommended that the facility define a process for patient anticoagulation-related calls outside normal business hours.
Closure Date:
5 We recommended that the facility review quality assurance data for the anticoagulation management program quarterly and that facility managers monitor compliance.
Closure Date:
6 We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
Closure Date:
7 We recommended that facility managers ensure that clinicians consistently obtain all required laboratory tests prior to initiating anticoagulation warfarin treatment and that clinicians obtain initial prothrombin/international normalized ratio through laboratory testing.
Closure Date:
8 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
Closure Date:
9 We recommended that providers consistently complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
10 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:
11 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
Closure Date:
12 We recommended that facility managers ensure that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility¿s capacity and monitor compliance.
Closure Date:
13 We recommended that for patients transferred out of the facility, providers document sending or communicating to the accepting facility available history; observations, signs, symptoms, and preliminary diagnoses; and results of diagnostic studies and tests and that facility managers monitor compliance.
Closure Date:
14 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:
15 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
Closure Date:
16 We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
Closure Date:
17 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 monitor compliance.
Closure Date:
18 We recommended that facility clinical managers ensure a clinician member of the Disruptive Behavior Committee enters progress notes regarding Patient Record Flags and ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement.
Closure Date:
19 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:
20 We recommended that clinicians provide education and counseling to patients with positive alcohol screens and who reported drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
Closure Date:
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| 16-00748-319 | Healthcare Inspection - Management of Mental Health Care Concerns, Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Mental Health Residential Rehabilitation Treatment Program local policies are consistent with the Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Handbook and Mental Health Residential Treatment Program leaders and staff adhere to the policies.
Closure Date:
2 We recommended that the Facility Director ensure that the Mental Health Residential Rehabilitation Treatment Program managers monitor compliance as outlined by Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Handbook.
Closure Date:
3 We recommended that the Facility Director ensure that the Mental Health Residential Rehabilitation Treatment Program has adequate resources, including staff, as specified by the Mental Health Residential Rehabilitation Treatment Program Handbook to provide a safe therapeutic environment.
Closure Date:
4 We recommended that the Facility Director ensure full implementation of the Acute Mental Health Inpatient Unit visitation policy and monitor for compliance.
Closure Date:
5 We recommended that the Facility Director implement assignments of Mental Health Treatment Coordinators to mental health patients and strategies to enhance communication and coordination across mental health clinical areas.
Closure Date:
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15039