Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-03508-275 | Administrative Investigation - Conflicting Interests and Misuse of Government Equipment, Overton Brooks VA Medical Center, Shreveport, Louisiana | Administrative Investigation | ||
1 We recommend that the VAMC Director confer with the Offices of
General Counsel, Human Resources, and Accountability Review to determine the appropriate administrative action to take, if any, against Dr. (name redacted).
Closure Date:
2 We recommend that the VAMC Director confer with the Offices of
General Counsel, Human Resources, and Accountability Review to determine the appropriate administrative action to take, if any, against Ms. (name redacted).
Closure Date:
3 We recommend that until such time as Congress either repeals or
modifies 38 USC § 3683, VA OGC Ethics Group should also focus on 38 USC § 3683 in their annual Ethics training for all VA employees.
Closure Date:
4 We recommend that VA OGC either enforce the law as written, or
initiate the waiver provision found in subsection (d) of the statute.
Closure Date:
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| 16-00549-302 | Clinical Assessment Program Review of the Aleda E. Lutz VA Medical Center, Saginaw, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data every 6 months and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility clinical managers ensure an interdisciplinary group reviews utilization management data and that facility managers monitor compliance.
Closure Date:
3 We recommended that facility repair malfunctioning medication carts or remove them from service.
Closure Date:
4 We recommended that clinicians ensure patients newly
prescribed warfarin have an international normalized ratio measurement taken within
7 days of warfarin initiation and that facility managers monitor compliance.
Closure Date:
5 We recommended that facility managers ensure transfer notes
written by acceptable designees document staff/attending physician approval and
contain a staff/attending physician countersignature and monitor compliance.
Closure Date:
6 We recommended that clinicians take and document all actions
required by the facility in response to test results and that clinical managers monitor
compliance.
Closure Date:
7 We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts prior to moderate sedation procedures and that facility managers monitor compliance.
Closure Date:
8 We recommended that clinical managers ensure that licensed independent practitioners who perform moderate sedation procedures complete required training for the provision of moderate sedation care and that training is documented and monitor compliance.
Closure Date:
9 We recommended that facility managers ensure all required disciplines attend Community Nursing Home Oversight Committee meetings.
Closure Date:
10 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
Closure Date:
11 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:
12 We recommended that facility managers ensure the Disruptive Behavior Committee [DBC] maintains meeting minutes and a record of attendance for key committee members and monitor compliance.
Closure Date:
13 We recommended that facility managers ensure employees consistently use the disruptive behavior reporting and tracking system and monitor compliance.
Closure Date:
14 We recommended that facility clinical managers ensure clinicians inform patients about the right to request to amend/appeal Patient Record Flag placement.
Closure Date:
15 We recommended that facility clinical managers ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
Closure Date:
16 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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| 16-00578-291 | Clinical Assessment Program Review of the El Paso VA Health Care System, El Paso, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers review Ongoing Professional Practice Evaluation data quarterly and that facility managers monitor compliance.
Closure Date:
2 We recommended that the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
3 We recommended that the facility consistently take actions when data analyses indicated problems or opportunities for improvement and evaluate them for effectiveness in root cause analyses and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility revise the policy for anticoagulation management to include an anticoagulation quality assurance program.
Closure Date:
5 We recommended that the facility develop and implement processes to address noncompliance with the treatment plan.
Closure Date:
6 We recommended that the facility define ways to minimize the risk of incorrect tablet strength dosing errors.
Closure Date:
7 We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications 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 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:
10 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
Closure Date:
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| 15-00509-301 | Quality of Care Concerns at Two Veterans Integrated Service Network 23 Facilities and a Veterans Readjustment Counseling Center | Hotline Healthcare Inspection | ||
1 We recommended that the St. Cloud VA Health Care System Director incorporate processes to ensure assessment of patient preference, plans for further treatment, and an adequate process for termination or transfer to VHA mental health services when non-VA mental health services are discontinued.
Closure Date:
2 We recommended that the St. Cloud VA Health Care System Director identify patients whose non-VA Post-Traumatic Stress Disorder services were terminated as discussed in this report, determine if the patients were offered and received mental health treatment, and take action as appropriate.
Closure Date:
3 We recommended that the Minneapolis VA Health Care System Director ensure compliance with Veteran Health Administration scheduling policies.
Closure Date:
4 We recommended that the Minneapolis VA Health Care System Director ensure compliance with Veteran Health Administration communication of test results policies.
Closure Date:
5 We recommended that the Chief Officer, Readjustment Counseling identify St. Paul Vet Center patients whose non-VA Post-Traumatic Stress Disorder services were terminated as discussed in this report, determine if the patients were offered and received mental health services, and take action as appropriate.
Closure Date:
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| 16-00568-292 | Clinical Assessment Program Review of the Oscar G. Johnson VA Medical Center, Iron Mountain, Michigan | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers implement a process to protect personally identifiable information on laboratory specimens at the Menominee community based outpatient clinic and monitor compliance.
Closure Date:
2 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:
3 We recommended that clinicians take and document all actions required by the facility in response to test results and that clinical managers monitor compliance.
Closure Date:
4 We recommended that the facility ensure integration of the community nursing home program into its quality improvement program.
Closure Date:
5 We recommended that facility managers ensure the Community Nursing Home Review Team completes required annual reviews and monitor compliance.
Closure Date:
6 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:
7 We recommended that a VA physician order or approve all therapies that are at VA expense.
Closure Date:
8 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.
Closure Date:
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| 16-02676-297 | Healthcare Inspection—Clinical Activities, Staffing, and Administrative Practices, Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma | Hotline Healthcare Inspection | ||
1 We recommended that the System Director take action to fill key leadership positions with qualified permanent personnel.
Closure Date:
2 We recommended that the System Director ensure that established workgroups continue efforts to improve Strategic Analytics for Improvement and Learning-related metrics, and that progress be monitored.
Closure Date:
3 We recommended the System Director ensure that the Quality, Safety and Value’s subordinate committee minutes comply with Veterans Health Administration policy.
Closure Date:
4 We recommended that the System Director ensure professional practice evaluations include performance data to support provider privileges and are conducted as outlined in Veterans Health Administration and local policy.
Closure Date:
5 We recommended that the System Director ensure that Service-level privilege lists are relevant to the care provided in the Service.
Closure Date:
6 We recommended that the System Director ensure use of the correct methodology to determine the severity assessment code for all reported patient safety events.
Closure Date:
7 We recommended that the Veterans Integrated Service Network Director consider an inter-rater reliability system or second-level review to ensure the correct application of the severity assessment code criteria.
Closure Date:
8 We recommended that the System Director ensure the local peer review policy includes all Veterans Health Administration policy requirements.
Closure Date:
9 We recommended that the System Director ensure adherence to all national peer review program requirements, including the use of suitable peers in Peer Review Committee processes, and monitor for compliance.
Closure Date:
10 We recommended that the System Director ensure a process is in place to identify and review cases where institutional disclosure may be indicated, and complete as appropriate.
Closure Date:
11 We recommended that the System Director continue efforts to recruit and hire for vacancies, and ensure that, until optimal staffing is achieved, alternate methods are consistently available to meet patient care needs.
Closure Date:
12 We recommended that the System Director continue efforts to enhance access to care for Specialty Care and Mental Health clinics and monitor outcomes for continued improvement.
Closure Date:
13 We recommended that the System Director continue efforts to enhance call center timeliness and monitor outcomes for continued improvement.
Closure Date:
14 We recommended the Veterans Integrated Service Network Director charter a team to conduct a follow-up site visit to ensure the System Director’s corrective actions taken in response to previous non-VA care-related recommendations were effective.
Closure Date:
15 We recommended that the System Director ensure that Patient Aligned Care Team clinicians follow Veterans Health Administration requirements for patient notification and follow-up of abnormal lab results.
Closure Date:
16 We recommended that the System Director monitor consult completion timeliness and identify process improvements for those exceeding 30 days.
Closure Date:
17 We recommended that the System Director ensure that a Mental Health-related Strategic Analytics for Improvement and Learning workgroup identify priorities, and develop and implement improvement actions accordingly.
Closure Date:
18 We recommended that the System Director ensure continued efforts to improve lengths of stay for patients being discharged from the Emergency Department.
Closure Date:
19 We recommended that the System Director ensure that all patient care areas comply with environment of care requirements and that action plans specifically address deficient areas identified in this report.
Closure Date:
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| 14-03822-289 | Healthcare Inspection – Alleged Staffing, Quality of Care, and Administrative Deficiencies, Amarillo VA Health Care System, Amarillo, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director continue efforts to recruit and hire for nursing staff vacancies, and ensure that until optimal staffing is achieved, alternate methods are consistently available to meet patient care needs.
Closure Date:
2 We recommended that the Facility Director ensure members consistently attend Pressure Ulcer Committee meetings and document efficacy data on specific treatments, information on new treatment modalities, and action items, to include documentation of follow-up taken regarding action items.
Closure Date:
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| 15-03357-180 | Review of Alleged Mismanagement of VHA's Patient Transportation Service Contract for the Jesse Brown VAMC in Chicago, IL | Audit | ||
1 We recommended the Acting Chief Procurement and Logistics Officer,Veterans Health Administration, ensure the Great Lakes AcquisitionCenter complies with Department of Veterans Affairs and VeteransHealth Administration’s policies to perform Integrated OversightReviews.
Closure Date:
2 We recommended the Acting Chief Procurement and Logistics Officer,Veterans Health Administration, ensure the Great Lakes AcquisitionCenter complies with Department of Veterans Affairs’ policy fordocumenting contract information in the Electronic ContractManagement System.
Closure Date:
3 We recommended the Acting Chief Procurement and Logistics Officer,Veterans Health Administration, ensure the Great Lakes AcquisitionCenter performs appropriate competition for future patient transportationservice contracts.
Closure Date:
4 We recommended the Acting Chief Procurement and Logistics Officer,Veterans Health Administration, work with the Chief Financial Officer, Veterans Health Administration, to determine if an Antideficiency Act violation occurred and take action as deemed appropriate.
Closure Date:
5 We recommended the Acting Chief Procurement and Logistics Officer, Veterans Health Administration, require all Great Lakes Acquisition Center’s patient transportation service contracts be reviewed for compliance with Federal Acquisition Regulation regardless of the financial thresholds in the proposed contract award.
Closure Date:
6 We recommended the Acting Chief Procurement and Logistics Officer, Veterans Health Administration, work with the Head of Contracting Activity, Service Area Office Central to review and assess the contracting officers’ warrant authority and take action as deemed appropriate.
Closure Date:
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| 15-01217-249 | Review of Alleged Irregular Use of Purchase Cards by VHA’s Engineering Service at the Carl Vinson VA Medical Center in Dublin, Georgia | Audit | ||
1 We recommended the Veterans Integrated Service Network 7 Director review VA Medical Center Dublin¿s micro-purchase card transactions made by Engineering Service cardholders from October 2012 through March 2017 to identify unauthorized commitments.
Closure Date:
2 We recommended the Veterans Integrated Service Network 7 Director submit ratification requests for unauthorized commitments identified in this report and Veterans Integrated Service Network 7 to the Veterans Health Administration's Head of Contracting Activity.
Closure Date:
3 We recommended the Veterans Integrated Service Network 7 Director issue a memo to the VA Medical Center Dublin Director emphasizing the importance of approving officials monitoring cardholder purchases for adherence to Government charge card requirements in Federal and VA regulations and VA policies and the consequences of failing to adhere to these requirements.
Closure Date:
4 We recommended the Veterans Integrated Service Network 7 Director require VA Medical Center Dublin Engineering Service cardholders and approving officials to receive focused training on not splitting purchases, procuring supplies and services without proper authority, and making purchases exceeding established dollar limits.
Closure Date:
5 We recommended the Veterans Integrated Service Network 7 Director require VA Medical Center Dublin to establish an oversight mechanism to ensure approving officials without the required approval are assigned no more than 10 cardholders each.
Closure Date:
6 We recommended the Veterans Integrated Service Network 7 Director take appropriate administrative action for each cardholder who made unauthorized commitments.
Closure Date:
7 We recommended the Veterans Integrated Service Network 7 Director require VA Medical Center Dublin to establish an oversight mechanism to ensure approving officials adequately review cardholder purchases of recurring services from vendors expected to exceed $5,000 during a fiscal year to ensure contracts are established in accordance with Veterans Health Administration policy.
Closure Date:
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| 14-01451-276 | Healthcare Inspection – Non-VA Colonoscopy Follow-Up Concerns, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that all potentially affected patients, as described in this report, be reviewed by an external (non-system) source to ensure those patients received follow-up care.
Closure Date:
2 We recommended that the System Director confer with the Office of Chief Counsel (formerly Regional Counsel) regarding Patients 2 and 3 described in this report for possible institutional disclosure, and take action as appropriate.
Closure Date:
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14957