Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-00569-253 | Clinical Assessment Program Review of the Atlanta VA Medical Center, Decatur, Georgia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently review Ongoing Professional Practice Evaluation data semi-annually and that facility managers monitor compliance.
Closure Date:
2 We recommended that facility clinical managers ensure peer reviewers consistently document their evaluation of at least one of the important aspects of care and that facility managers monitor compliance.
Closure Date:
3 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:
4 We recommended that Environment of Care Committee meeting minutes document discussion of environment of care rounds deficiencies, include corrective actions taken to address rounds deficiencies, and track actions taken in response to identified deficiencies to closure.
Closure Date:
5 We recommended that facility managers ensure information technology network room logs for visitors contain all required information to document access and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure ventilation grills and floors in patient care areas are clean and monitor compliance.
Closure Date:
7 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
Closure Date:
8 We recommended that facility managers ensure ice machines in patient nourishment kitchens are clean and monitor compliance.
Closure Date:
9 We recommended that the facility develop and implement a policy that addresses anticoagulation management.
Closure Date:
10 We recommended that the facility designate a physician anticoagulation program champion.
Closure Date:
11 We recommended that clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and that facility managers monitor compliance.
Closure Date:
12 We recommended that providers complete transfer documentation for patients transferred out of the facility and that facility managers monitor compliance.
Closure Date:
13 We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
Closure Date:
14 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:
15 We recommended that employees ensure glucometers are clean before and after use and that clinical managers monitor compliance.
Closure Date:
16 We recommended that the facility implement an Employee Threat Assessment Team or an alternate group that addresses employee-related disruptive behavior.
Closure Date:
17 We recommended that the Patient Safety Manager and/or Risk Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
Closure Date:
18 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:
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 facility clinical managers ensure that all patients discharged with pressure ulcers have wound care follow-up plans and receive dressing supplies prior to being discharged and that facility managers monitor compliance.
Closure Date:
21 We recommended that employees consistently complete diagnostic assessments for patients with a positive alcohol screen and that facility managers monitor compliance.
Closure Date:
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| 15-04351-188 | Review of Alleged Inappropriate Contract Actions Related to VA’s Lease of a Digital Imaging Network-Picture Archival Communication System | Audit | ||
1 We recommended the Deputy Assistant Secretary for Acquisition and Logistics develop procedures to ensure acquisition teams fully comply with the fundamental requirements of the Federal Acquisition Regulation on all Digital Imaging Network-Picture Archival Communication System acquisitions.
Closure Date:
2 We recommended the Deputy Assistant Secretary for Acquisition and Logistics ensure adequate oversight reviews are conducted for the Digital Imaging Network-Picture Archival Communication System to ensure contracting officers comply with Department of Defense contract terms to obtain commercial price lists by using the Contractor Price Book Spreadsheet.
Closure Date:
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| 15-01080-208 | Review of Alleged Overpayments for Non-VA Care Made by Florida VA Facilities | Audit | ||
1 We recommended the Under Secretary for Health develop and implement a plan to ensure all non-VA physician-administered drugs (other than orally administered) are paid in accordance with the Code of Federal Regulations.
Closure Date:
2 We recommended the Under Secretary for Health develop a plan for uploading Medicare rates into the Fee Basis Claims System to enable the proper payment of physician-administered drug claims.
Closure Date:
3 We recommended the Under Secretary for Health issue bills of collection, as necessary and in accordance with VA policy, to recover physician-administered drug overpayments made by Florida VA facilities.
Closure Date:
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| 16-00581-239 | Clinical Assessment Program Review of the Birmingham VA Medical Center, Birmingham, Alabama | 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 Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and that facility managers monitor compliance.
Closure Date:
3 We recommended that facility managers ensure floors in patient care areas are clean and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure sharps containers stored for pick-up are secured and monitor compliance.
Closure Date:
5 We recommended that for patients transferred out of the facility, providers consistently include documentation of patient or surrogate informed consent in transfer documentation and that facility managers monitor compliance.
Closure Date:
6 We recommended that facility managers ensure transfer notes written by acceptable designees contain a staff/attending physician countersignature and monitor compliance.
Closure Date:
7 We recommended that for patients transferred out of the facility, sending nurses document transfer assessments/notes and that facility managers monitor compliance.
Closure Date:
8 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 that facility managers monitor compliance.
Closure Date:
9 We recommended that facility managers ensure the Community Nursing Home Oversight Committee includes representation by all required clinical disciplines.
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 clinical managers ensure clinicians inform patients about the Patient Record Flags and the right to request to amend/appeal Patient Record Flag placement and ensure Chief of Staff or designee approval of Orders of Behavioral Restriction.
Closure Date:
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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| 16-01077-255 | Opioid Management Practice Concerns, John J. Pershing VA Medical Center Popular Bluff, Missouri | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director develop processes to ensure that the relevant providers complete timely patient evaluations for continued long-term opioid therapy for pain based on clinically significant changes or findings to a patient’s health status.
Closure Date:
2 We recommended that the Facility Director ensure that reviews of the cases of the identified patients with clinically significant changes are completed and take action as appropriate.
Closure Date:
3 We recommended that the Facility Director ensure that the relevant providers receive education on the concurrent prescribing of dual short acting opioids and tapering of opioids.
Closure Date:
4 We recommended that the Facility Director ensure that the relevant providers review Veterans Health Administration recommendations regarding the use of opioid risk stratification tools, such as the Opioid Risk Tool, to identify high-risk patients for longterm opioid therapy for pain.
Closure Date:
5 We recommended that the Facility Director ensure that the relevant providers order urine drug screening frequency based on risk assessment and complete urine drug screening at least annually.
Closure Date:
6 We recommended that the Facility Director ensure that the relevant providers consistently use urine drug screening confirmatory testing.
Closure Date:
7 We recommended that the Facility Director develop processes that minimize the potential for urine drug screening tampering.
Closure Date:
8 We recommended that the Facility Director ensure that the relevant providers consistently complete the informed consent process prior to initiating long-term opioid therapy for pain as specified by Veterans Health Administration policy.
Closure Date:
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| 16-00327-209 | Review of Alleged Mismanagement of VA's Human Resources and Administration Contract Funds | Audit | ||
1 We recommended the Acting Assistant Secretary for Human Resources and Administration assign responsibility to an office to assess hosting solution options for the Dashboard Tool.
Closure Date:
2 We recommended the Acting Assistant Secretary for Human Resources and Administration evaluate funding a hosting solution needed to test and use its estimated $3.7 million Dashboard Tool investment.
Closure Date:
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| 15-01043-247 | Healthcare Inspection – Alleged Unsafe Blood Transfusion Practices, Battle Creek VA Medical Center, Battle Creek, Michigan | Hotline Healthcare Inspection | ||
1 We recommended that the Battle Creek VA Medical Center Director ensure that Battle Creek VA Medical Center managers update the blood transfusion policy to align with AABB blood transfusion guidelines.
Closure Date:
2 We recommended that the Battle Creek VA Medical Center Director ensure that providers follow Battle Creek VA Medical Center policy and report all transfusion adverse reactions to the Blood Usage Review Committee for review.
Closure Date:
3 We recommended that the Battle Creek VA Medical Center Director ensure that the Transfusion Officer who is appointed to the Blood Usage Review Committee has no conflict of interest between committee and professional responsibilities.
Closure Date:
4 We recommended that the Battle Creek VA Medical Center Director ensure that for level 2 and level 3 peer reviews, the Peer Review Committee provide recommendations to supervisors of non-punitive and non-disciplinary actions, that supervisors discuss and follow up with providers, and that Peer Review Committee minutes include documentation of actions and of supervisory follow-up as required by the Veterans Health Administration.
VA
Closure Date:
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| 15-05235-200 | Review of Alleged Removal of Workload Controls at the VARO in San Juan, PR | Audit | ||
1 We recommended the San Juan VA Regional Office Director develop and implement a plan to review the 722 End Product 930s that staff removed from its inventory in August and September 2015.
Closure Date:
2 We recommended the San Juan VA Regional Office Director monitor the effectiveness of current plans to manage the End Product 930 workload.
Closure Date:
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| 16-03302-252 | Healthcare Inspection – Nutrition and Food Service Environment of Care Concerns, Edward Hines, Jr. VA Hospital, Hines, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director complete an analysis of the basement and sub-basement structures to determine if adequate measures are in place to prevent water infiltration.
Closure Date:
2 We recommended that the Facility Director ensure that Nutrition and Food Service kitchen staffing is sufficient to perform all required duties including cleaning and sanitation.
Closure Date:
3 We recommended that the Facility Director complete an analysis of the feasibility of relocating the main kitchen to an area that limits the environmental conditions for pests.
Closure Date:
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| 15-01669-246 | Healthcare Inspection—Patient Deaths, Opioid Prescribing Practices, and Consult Management, VA Greater Los Angeles Healthcare System, | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure staff conduct a review of canceled or discontinued cardiology consults to determine if patients suffered harm as a result of inappropriate consult closure and confer with the Office of Chief Counsel regarding disclosure as necessary.
2 We recommended that the System Director ensure system staff comply with current Veterans Health Administration policies regarding consult management.
Closure Date:
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14957