Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-03303-206 | Review of VHA Care and Privacy Standards for Women Veterans | National Healthcare Review | ||
1 We recommended that the Acting Under Secretary for Health ensure that the Office of Women’s Health Services routinely reviews and when appropriate, strengthens the requirements for women’s health provider designation and facilitates the updating of requirements for all designated women health providers with supporting documentation that details how the requirements were satisfied.
Closure Date:
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| 15-05123-254 | Healthcare Inspection – Alleged Misdiagnosis and Delay in Treatment, Providence VA Medical Center, Providence, Rhode Island | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that peer reviews are completed and reported as required by Veterans Health Administration policy.
Closure Date:
2 We recommended that the Facility Director ensure that peer reviews are completed and reported as required by Veterans Health Administration policy.
Closure Date:
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| 17-01542-273 | Healthcare Inspection Sterile Compounding Environment and Practices, Overton Brooks VA Medical Center, Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that facility leaders implement corrective actions and processes to fully comply with United States Pharmacopeia 797> requirements, test the effectiveness of these actions and processes before resuming full compounded sterile preparations operations, and monitor compliance of key elements through a facility or Veterans Integrated Service Network-level committee.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director issue guidance to facility staff requiring that results of external reviews be provided to facility leaders as soon as those results are available.
Closure Date:
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| 15-03678-210 | Review of Alleged Unauthorized Commitments for Prosthetic Purchases at VA Network Contracting Office 3 | Audit | ||
1 We recommend the Director of Contracting, NCO 2 submit a ratification request for the unauthorized commitments identified in this report to the cognizant Head of Contracting Activity – Executive Director, Service Area Office East.
Closure Date:
2 We recommend the Director of Contracting, NCO 2 submit a ratification request for the unauthorized commitments identified in this report to the cognizant Head of Contracting Activity – Executive Director, Service Area Office East.
Closure Date:
3 We recommend the Executive Director, Service Area Office East conduct a review of Network Contracting Office operations to ensure internal controls, such as segregation of duties, are monitored and enforced.
Closure Date:
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| 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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| 16-01077-255 | 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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| 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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15039