Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 16-03920-197 | Evaluation of Computed Tomography Radiation Monitoring in Veterans Health Administration Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure a medical physicist inspects computed tomography scanners after completion of repairs or modifications that affect the dose or image quality prior to returning the scanners to clinical service.
Closure Date:
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| 16-00376-133 | Review of Unauthorized System Interconnection at the VA Regional Office in Wichita, Kansas | Audit | ||
1 We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
Closure Date:
2 We recommended the Assistant Secretary for Information and Technology implement review processes to monitor the performance of the facility chief information officers, information security officers, and technical staff on the identification of external system interconnections and the required change control processes.
Closure Date:
3 We recommended the Assistant Secretary for Information and Technology, in conjunction with the Wichita VA Regional Office Director, ensure that VA's system interconnection with the Kansas Commission on Veterans Affairs Office is brought into compliance with VA Information Security requirements and is authorized by an Interconnection Security Agreement and Facility Compliance Report.
Closure Date:
4 We recommended the Assistant Secretary for Information and Technology conduct an annual review of all Veterans Service Organization systems connected to VA¿s network and ensure that appropriate Interconnection Service Agreements are in place and enforced for those connections.
Closure Date:
5 We recommended the Assistant Secretary for Information Technology implement improved change management controls to prevent the establishment of Virtual Private Network concurrent network connections that are not in accordance with VA policy.
Closure Date:
6 We recommended the Director of the Wichita VA Regional Office implement a local process for managing all Veterans Service Organization service requests and document pertinent roles and responsibilities within a Memorandum of Understanding.
Closure Date:
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| 16-00572-179 | Clinical Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah | 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 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 Environment of Care Committee meeting minutes consistently document discussion of environment of care rounds deficiencies, the specific deficiencies, corrective actions taken to address identified deficiencies, and resolutions.
Closure Date:
4 We recommended that facility managers ensure attendance is documented for all fire drills.
Closure Date:
5 We recommended that facility managers ensure fire drills have documented critiques.
Closure Date:
6 We recommended that facility managers ensure eye protection equipment is readily available for employees.
Closure Date:
7 We recommended that facility managers ensure standard operating procedures for the colonoscopes and endoscopes for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography are consistent with manufacturer instructions for use.
Closure Date:
8 We recommended that Sterile Processing Service managers ensure Sterile Processing Service employees receive training at orientation for the types of reusable medical equipment they reprocess.
Closure Date:
9 We recommended that the facility consistently review and report all quality assurance data measures for the anticoagulation management program quarterly and that facility managers monitor compliance.
Closure Date:
10 We recommended that for employees actively involved in the anticoagulant program, clinical managers include in competency assessments knowledge of standard terminology, pharmacology of anticoagulants, monitoring requirements, dose calculation, common side effects, nutrient interactions associated with anticoagulation therapy, and drug to drug interactions associated with anticoagulation therapy and that facility managers monitor compliance.
Closure Date:
11 We recommended that the facility collect and report data on patient transfers out of the facility.
Closure Date:
12 We recommended that the facility monitor and evaluate patient transfers as part of the quality management program.
Closure Date:
13 We recommended that the Chief of Pathology and Laboratory Medicine Service ensure the point-of-care testing procedure manual is readily available to employees.
Closure Date:
14 We recommended that the Chief of Pathology and Laboratory Medicine Service ensure employees who perform point-of-care glucose testing comply with facility policy for managing critical glucose values.
Closure Date:
15 We recommended that providers include history of previous adverse experience with sedation or anesthesia in the history and physical and/or pre-sedation assessment and that facility managers monitor compliance.
Closure Date:
16 We recommended that clinical teams, including the providers performing the procedures, conduct and document timeouts using a checklist prior to moderate sedation procedures and that facility managers monitor compliance.
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 and monitor compliance.
Closure Date:
18 We recommended that the Patient Safety Manager and Patient Advocate consistently attend Disruptive Behavior Committee meetings.
Closure Date:
19 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:
20 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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| 15-04976-191 | Healthcare Inspection – Alleged Quality of Care Concerns, VA Greater Los Angeles Healthcare System, Los Angeles, California | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that nursing staff comply with pressure ulcer documentation requirements and physician providers routinely document participation in the interdisciplinary plan for patients with pressure ulcers.
Closure Date:
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| 15-05379-146 | Audit of VHA's Patient Advocacy Program | Audit | ||
1 We recommended the Under Secretary for Health update patient advocate policies and procedures to ensure they meet current needs.
Closure Date:
2 We recommended the Under Secretary for Health develop procedures to ensure pertinent program information is recorded in a standardized format in the Patient Advocate Tracking System.
Closure Date:
3 We recommended the Under Secretary for Health ensure responsible officials and staff perform patient complaint processing activities in accordance with policies and procedures, such as assuring required program information is recorded and trended at the local and national level.
Closure Date:
4 We recommended the Under Secretary for Health work with the Assistant Secretary for Information and Technology to ensure its Patient Advocate Tracking System meets current program requirements for efficient complaint processing and reporting.
Closure Date:
5 We recommended the Under Secretary for Health establish controls to ensure that patient advocate staffing levels are sufficient to support patient advocate workload estimates.
Closure Date:
6 We recommended the Under Secretary for Health provide patient advocates with periodic formal documented training concerning their responsibilities and utilizing the Patient Advocate Tracking System.
Closure Date:
7 We recommended the Under Secretary for Health implement mechanisms to ensure that privileges and access rights to the Patient Advocate Tracking System are regularly reviewed and extended based upon specific job duties and the need to know.
Closure Date:
8 We recommended the Assistant Secretary for Information and Technology work with the Under Secretary for Health to fully assess the Patient Advocate Tracking System security and operational risks and to initiate appropriate corrective actions, including requesting the authority to operate the Patient Advocate Tracking System, if appropriate.
Closure Date:
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| 16-03743-193 | Evaluation of the Quality, Safety, and Value Program in Veterans Health Administration Facilities Fiscal Year 2016 | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure clinical managers evaluate licensed independent practitioners’ ongoing professional performance regularly according to the frequency required by facility policy.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers and facility senior managers, ensure clinical managers implement the improvement actions recommended by the Peer Review Committee.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Utilization Managers complete at least 75 percent of all required reviews and designated Physician Utilization Management Advisors document their review decisions in the Veterans Health Administration’s utilization management database.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure Patient Safety Managers enter all patient incidents into the Veterans Health Administration’s web-based patient incident database, complete the minimum number of root cause analyses, provide feedback about the root cause analyses findings to the individuals or departments who reported the incidents, and submit patient safety reports to facility leaders at least annually.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure committees and teams consistently implement and evaluate corrective actions from quality, safety, and value activities.
Closure Date:
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| 16-02806-182 | Review of Alleged Use of Incorrect Effective Dates at VBA's VARO in Chicago, IL | Audit | ||
1 We recommended the Chicago VA Regional Office Director conduct a review of the 586 claims with intent to files remaining from our universe, completed from October 1, 2015 through March 31, 2016, and take appropriate actions and report results back to OIG.
Closure Date:
2 We recommended the Chicago VA Regional Office Director implement a plan to ensure sufficient analysis of quality reviews is completed to identify effective date errors related to intent to files.
Closure Date:
3 We recommended the Chicago VA Regional Office Director ensure claims processors receive training on how to identify intent to files.
Closure Date:
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| 16-00575-147 | Clinical Assessment Program Review of the Canandaigua VA Medical Center, Canandaigua, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees actively involved in the anticoagulant program complete competency assessments annually and that clinical managers monitor compliance.
Closure Date:
2 We recommended that clinicians document interventions and provider communication for glucometer critical values with the required template and that clinical managers monitor compliance.
Closure Date:
3 We recommended that the facility establish a Community Nursing Home Oversight Committee.
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 social workers and registered nurses conduct and document cyclical clinical visits with the frequency required by Veterans Health Administration policy and monitor compliance.
Closure Date:
6 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:
7 We recommended that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens.
Closure Date:
8 We recommended that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens.
Closure Date:
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| 16-00252-137 | Audit of VHA’s Alleged Improper Payments to Providers After Veterans’ Reported Deaths | Audit | ||
1 We recommended the Under Secretary for Health recover the reported improper payments for outpatient services that could not have been rendered to deceased veterans.
Closure Date:
2 We recommended the Under Secretary for Health ensure medical facilities adhere to VHA Procedure Guide 1601F.02 and update non-VA care authorization end dates for deceased veterans.
Closure Date:
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| 15-03231-319 | Review of Alleged Mismanagement of Construction Projects at the VA Medical Center in Clarksburg, West Virginia | Audit | ||
1 We recommended the Veterans Integrated Service Network 5 Director implement a plan to use or repurpose the heating and air conditioning system identified by this review.
Closure Date:
2 We recommended the Veterans Integrated Service Network 5 Director ensure the Louis A. Johnson VA Medical Center staff responsible for Independent Government Cost Estimates receive appropriate training.
Closure Date:
3 We recommended the Veterans Integrated Service Network 5 Director implement procedures to ensure the Louis A. Johnson VA Medical Center staff develop reliable Independent Government Cost Estimates for all construction projects.
Closure Date:
4 We recommended the Veterans Integrated Service Network 5 Director implement procedures to ensure the Louis A. Johnson VA Medical Center staff develop reliable Independent Government Cost Estimates for all construction projects.
Closure Date:
5 We recommended the Veterans Integrated Service Network 5 Director establish controls to ensure needed site surveys are performed timely during project planning for construction projects.
Closure Date:
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15039