Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-05255-422 | Audit of VHA’s Consolidated Mail Outpatient Pharmacy Program | Audit | ||
1 We recommended the Under Secretary for Health ensure the Consolidated Mail Outpatient Pharmacies¿ Logistics Officer and Director or Associate Director review all inventory adjustments and approve adjustment documentation monthly as required by CMOP Inventory Management and Control national policy.
Closure Date:
2 We recommended the Under Secretary for Health ensures Consolidated Mail Outpatient Pharmacy National Office implements a mechanism to validate self-reported data to ensure the reliability of its core quality metrics.
Closure Date:
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| 14-04898-290 | Healthcare Inspection – Teleradiology Concerns, VA Roseburg Healthcare System, Roseburg, Oregon | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director conduct a quality review of the imaging study interpretations completed during the time of the unsigned Memorandum of Understanding referenced in this report.
Closure Date:
2 We recommended that the System Director strengthen processes to ensure the Radiology Services is fully integrated into the system's formal peer review program.
Closure Date:
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| 15-00506-420 | Healthcare Inspection – Nurse Staffing and Patient Safety Reporting Concerns, VA Roseburg Healthcare System, Roseburg, Oregon | Hotline Healthcare Inspection | ||
1 We recommended that the System Director strengthen processes to ensure staffing levels are analyzed and documented in applicable safety and quality of care reviews and annually reported to leadership.
Closure Date:
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| 15-04672-342 | Review of Alleged Consult Management Issues at the Phoenix VA Health Care System | Audit | ||
1 We recommended the Under Secretary for Health update the Veterans Health Administration Consult Policy.
2 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System communicate consult policies and procedures to all facility staff and providers to ensure consistent procedures and responsibilities to effectively manage and schedule consults.
3 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System develop a routine review of closed consults to ensure staff are appropriately discontinuing and documenting consults in accordance with national and local policy.
Closure Date:
4 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure respective services follow up with the patients identified in this review for appropriate action.
5 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Chiropractic Services review all consults canceled by the service since January 1, 2015, for appropriate action.
Closure Date:
6 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System ensure that the care of the patient identified in the reported case summary is evaluated, takes action, if appropriate, and confers with Regional Counsel regarding the appropriateness of disclosures to patients and families.
7 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System develop a mechanism to ensure that Quality, Safety, and Improvement services appropriately review deceased patients’ records with an open consult, and staff timely and appropriately close the consult upon verification of death by Decedent Affairs.
8 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure services assign and maintain appropriate and sufficient clinical staff to receive and review consults within target time frames.
Closure Date:
9 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Human Resources and specialty care services fill vacant medical support assistant positions responsible for scheduling consults in specialty care services to ensure sufficient resources to manage and schedule consults.
Closure Date:
10 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System pursue an automated process to ensure Vascular Lab results are entered in the electronic medical records in order to eliminate reliance on printed lab results.
Closure Date:
11 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure Vascular Service review all incomplete Vascular Lab consults to identify and address all potential lost lab results.
Closure Date:
12 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure clinics coordinate with clinic informatics services to develop a mechanism to routinely identify and address open consults in which the corresponding appointment was already completed.
13 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System assign sufficient staff to manage non-VA care and Choice consults and appointments.
Closure Date:
14 We recommended the Veterans Integrated Service Network 22 Director ensure the director of Phoenix VA Health Care System make sure non-VA care develop a process to routinely follow up with those patients with open community care consults older than 120 days to determine if they received the requested care.
Closure Date:
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| 14-02890-425 | Review of an Alleged Radiology Exam Backlog at VHA’s W.G. (Bill) Hefner VAMC in Salisbury, NC | Audit | ||
1 We recommended the W.G. (Bill) Hefner VA Medical Center Directorrequire staff to review all unscheduled radiology exam orders that are30 days past the clinically indicated date and either cancel the orders ifthe exams are not needed or ensure the exams are scheduled.
Closure Date:
2 We recommended the W.G. (Bill) Hefner VA Medical Center Directormake unscheduled urgent and STAT (immediate) orders a priority in thestaff’s review of unscheduled radiology orders and ensure staff determinewhether any potential harm has occurred to patients due to the delays incare.
Closure Date:
3 We recommended the VA Mid-Atlantic Health Care Network Directorensure that the W.G. (Bill) Hefner VA Medical Center develops a plan toaddress existing demand for Radiology exams and ensures future patientsreceive access to exams in accordance with VHA policy.
Closure Date:
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| 15-00650-423 | Review of Alleged Waste of Funds at VHA's Madison VA Medical Center | Audit | ||
1 We recommended the Veterans Integrated Service Network 12 Acting Director ensure management at the William S. Middleton Veterans Hospital complies with the facility policy requiring all equipment requests contain sufficient and accurate information to justify the acquisition request.
2 We recommended the Veterans Integrated Service Network 12 Acting Director ensure all laser lead extractors within the Veterans Integrated Service Network are being utilized to the extent possible.
Closure Date:
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| 15-00084-370 | Healthcare Inspection – Surgical Service Concerns, Fayetteville VA Medical Center, Fayetteville, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that recommendations, if any, from other reviews of the surgical program be implemented.
Closure Date:
2 We recommended that the Facility Director implement procedures to ensure patients are adequately evaluated by medicine and anesthesia providers prior to surgery.
Closure Date:
3 We recommended that the Facility Director ensure that peer reviews are conducted as required when criteria are met.
Closure Date:
4 We recommended that the Facility Director implement processes to ensure that necessary surgical supplies, equipment, and instruments are available, functional, and duplicated as needed.
Closure Date:
5 We recommended that the Facility Director evaluate the organizational structure for parity concerning surgical technician positions.
Closure Date:
6 We recommended that the Facility Director ensure that the surgical post-operative clinic uses the same nurse staffing methodology as other outpatient clinics.
Closure Date:
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| 14-05118-147 | Audit of VBA's Post-9/11 G.I. Bill Tuition and Fee Payments | Audit | ||
1 We recommended the Acting Under Secretary for Benefits improve outreach by periodically requiring Education Liaison Representatives to review Post-9/11 G.I. Bill and Yellow Ribbon Program requirements, the School Certifying Official Handbook, and other available Veterans Benefits Administration training resources with School Certifying Officials to help them submit accurate and complete tuition and fee certifications.
Closure Date:
2 We recommended the Acting Under Secretary for Benefits develop risk profiles for schools that are prone to certification problems, improper payments, and missed recoupments; and implement a process to periodically review and verify the certification information submitted by these schools.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits incorporate improper payment and missed recoupment risk factors into Veterans Benefits Administration’s risk-based system for the prioritization and completion of compliance surveys.
Closure Date:
4 We recommended the Acting Under Secretary for Benefits revise the School Certifying Official Handbook to clarify guidance on allowable book and supply fees.
Closure Date:
5 We recommended the Acting Under Secretary for Benefits review and strengthen Education Service policies and controls regarding the discontinuance and recoupment of payments, repeated classes, and satisfactory academic progress to ensure compliance with Federal regulations and prevent possible education benefits abuse.
Closure Date:
6 We recommended the Acting Under Secretary for Benefits ensure that mitigating circumstances are properly verified and supporting documentation is obtained before tuition repayments are forgiven.
Closure Date:
7 We recommended the Acting Under Secretary for Benefits initiate action to recover identified improper payments when collections are deemed appropriate and reasonable.
Closure Date:
8 We recommended the Acting Under Secretary for Benefits review the identified missed recoupments to determine if collections would be appropriate and reasonable.
Closure Date:
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| 14-00875-325 | Healthcare Inspection – Delay in Care of a Lung Cancer Patient, Phoenix VA Health Care System, Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that primary care providers are notified of specialty evaluations and treatment plans so they can be involved in care coordination.
Closure Date:
2 We recommended that the System Director ensure that staff assesses patient learning needs, barriers, abilities and readiness to learn, and that related education is provided as required by local policy, and monitor for compliance.
Closure Date:
3 We recommended that the System Director ensure that all patients are annually screened for depression, or more frequently as indicated by existing or newly identified risks, and that system manager’s monitor for compliance.
Closure Date:
4 We recommended that the System Director ensure that documentation from non-VA clinical care, including radiology reports, are obtained and available in the electronic health record for review in a timely and consistent manner.
Closure Date:
5 We recommended that the System Director ensure that system staff place consults with urgency based on the needed response time.
6 We recommended that the System Director review facility service agreements and care coordination in order to better care for patients with complex diseases that require multi-specialty intervention.
7 We recommended that the System Director review this case and consult with the Office of Chief Counsel (formerly Regional Counsel) regarding the care provided and take action if appropriate.
Closure Date:
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| 15-01982-113 | Healthcare Inspection - Alleged Inappropriate Opioid Prescribing Practices, Rutherford County Community Based Outpatient Clinic, Rutherfordton, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that primary care providers are able to assess, treat, monitor, and reassess patients on chronic opioid therapy within the appropriate timeframe.
Closure Date:
2 We recommended that the Facility Director ensure that the Veterans¿ Integrated Pain Management Clinic meets non-opioid pain management needs of patients as evidenced by timely consultation completions.
Closure Date:
3 We recommended that the Facility Director consider the clinical and administrative demands of chronic opioid therapy care when determining appropriateness of primary care provider staffing and that staffing plans are in place for planned and unplanned provider vacancies and absences.
Closure Date:
4 We recommended that the Facility Director ensure that benzodiazepine appropriateness evaluations are completed as required for chronic opioid therapy patients with post-traumatic stress disorder.
Closure Date:
5 We recommended that the Facility Director ensure that primary care and mental health providers communicate and coordinate care for post-traumatic stress disorder patients receiving both opioids and benzodiazepines.
Closure Date:
6 We recommended that the Facility Director ensure regular communication between facility leadership and community based outpatient clinic leadership to support consistent high quality care.
Closure Date:
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15039