Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-03688-304 | Audit of VA’s Green Management Program Solar Panel Projects | Audit | ||
1 We recommend the Interim Assistant Secretary for Management strengthen controls to ensure facility officials inform officials in the contracting office of potential conflicts between solar panel projects and other projects.
Closure Date:
2 We recommended the Interim Assistant Secretary for Management identify and share best practices for executing timely interconnection agreements with utilities based on continued collaboration with other Federal agencies.
Closure Date:
3 We recommended the Interim Assistant Secretary for Management implement controls to periodically compare actual and expected solar power generation data to ensure the solar panel system is performing as planned.
Closure Date:
4 We recommended the Interim Assistant Secretary for Management conduct a lessons learned assessment for solar project delays and implement additional controls to ensure future solar panel projects are properly planned and managed.
Closure Date:
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| 16-01613-326 | Combined Assessment Program Summary Report – Evaluation of Surgical Complexity Support Services in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health ensure that the Veterans Health Administration establishes system-wide requirements for competency assessment and validation, including frequency, for nursing employees who provide post-anesthesia care after operational hours.
Closure Date:
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| 15-04248-305 | Audit of Modular Ramps Purchased by the Malcom Randall VA Medical Center Gainesville, Florida | Audit | ||
1 We recommended the Malcom Randall VA Medical Center Director develop and implement a quality review process to ensure staff only award purchase orders for modular ramps that are Americans with Disabilities Act compliant and perform follow-up with vendors to ensure installed ramps comply with the Americans with Disabilities Act.
2 We recommended the Malcom Randall VA Medical Center Director develop a formal plan to identify training needs of staff responsible for purchasing modular ramps and ensure staff are trained periodically and appropriately.
3 We recommended the Malcom Randall VA Medical Center Director update written procedures to reflect the requirement that staff ensure vendor compliance with Americans with Disabilities Act standards for installed modular ramps.
4 We recommend the Malcom Randall VA Medical Center Director formally require vendors to provide modular ramp measurements in bid submissions and post-installation photographs.
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| 13-02255-276 | Audit of VBA's Compensation and Pension Benefit Payments to Incarcerated Veterans | Audit | ||
1 We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and issue bills of collection to recover improper payments made to veterans while they were incarcerated.
Closure Date:
2 We recommended the Acting Under Secretary for Benefits review the data on Federal incarcerations from May 2008 through June 2015 and take action to make appropriate benefits adjustments and issue bills of collection to recover improper payments for veterans currently incarcerated in Federal penal institutions.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits increase the priority placed on the Federal incarceration adjustment workload by using monthly data on Federal incarcerations to make appropriate and timely compensation and pension benefits adjustments.
Closure Date:
4 We recommended the Acting Under Secretary for Benefits monitor the terms of the current agreement with the Bureau of Prisons and take timely action to extend the agreement when appropriate.
Closure Date:
5 We recommended the Acting Under Secretary for Benefits increase the priority placed on state and local incarceration adjustment workload by initiating timely development action after receiving notifications of incarceration from the Social Security Administration.
Closure Date:
6 We recommended the Acting Under Secretary for Benefits increase priority of state and local incarceration adjustment workload by making timely incarceration adjustments and issue bills of collection to recover improper payments, as appropriate, after providing due process notification to veterans.
Closure Date:
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| 15-01296-203 | Community Based Outpatient Clinics Summary Report – Evaluation of Alcohol Use Disorder Care at Community Based Outpatient Clinics and Other Outpatient Clinics | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff complete diagnostic assessments for patients with a positive alcohol screen and that managers monitor for compliance.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic staff document the offer of further treatment to patients diagnosed with alcohol dependence and that managers monitor for compliance.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care and that managers monitor for compliance.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinic providers and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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| 16-00028-337 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Amarillo VA Health Care System, Amarillo, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the clinic manager ensures the risk of
infection is minimized when storing and disposing of medical waste at the Childress VA
Clinic.
Closure Date:
2 We recommended that the clinic manager ensures that exit
routes are unobstructed at the Childress VA Clinic.
Closure Date:
3 We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
Closure Date:
4 We recommended that the Facility Director ensures the
installation and use of an alarm system or panic buttons in high-risk areas at the Childress VA Clinic.
Closure Date:
5 We recommended that staff at the Childress VA Clinic protect and secure patient-identifiable information.
Closure Date:
6 We recommended that the Childress VA Clinic manager ensures that the information technology server closet is maintained according to information technology safety and security standards.
Closure Date:
7 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
9 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their laboratory results.
Closure Date:
10 We recommended that clinicians consistently provide and document interventions for clinically significant abnormal laboratory results.
Closure Date:
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| 16-00116-323 | Combined Assessment Program Review of the VA Connecticut Healthcare System, West Haven, Connecticut | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility clinical managers consistently 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 the Patient Safety Manager consistently enter all reported patient incidents into the WEBSPOT database and that facility managers monitor compliance.
Closure Date:
4 We recommended that the facility repair damaged furniture in patient care areas or remove it from service.
Closure Date:
5 We recommended that facility managers ensure employees follow facility policy for disinfecting exam tables after each patient use and monitor compliance.
Closure Date:
6 We recommended that facility managers ensure annual competency assessment for pharmacy employees who prepare compounded sterile products includes a written test and monitor compliance.
Closure Date:
7 We recommended that employees ask inpatients whether they would like to discuss creating, changing, and/or revoking advance directives and that facility managers monitor compliance.
Closure Date:
8 We recommended that the Suicide Prevention Coordinators consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
Closure Date:
9 We recommended that nurse managers accurately monitor the nurse staffing methodology implemented in March 2013 and use the standard nursing hours per patient day calculation to assess nurse staffing adequacy for all units.
Closure Date:
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| 15-03867-287 | Healthcare Inspection - Access and Quality of Care Concerns, Phoenix VA Health Care System, Phoenix, Arizona, and Delayed Test Result Notification, Minneapolis VA Health Care System, Minneapolis, Minnesota | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to improve Emergency Department access and flow during times of increased demand.
Closure Date:
2 We recommended that the Acting Veterans Integrated Service Network 18 Director assign a team to review the Phoenix VA Health Care System Emergency Department processes and develop a plan to decrease the number of patients who leave the Emergency Department without being seen by a provider.
Closure Date:
3 We recommended that the Phoenix VA Health Care System Director review current verbal communication practices in the Emergency Department and determine what steps are reasonable to safeguard patient information.
Closure Date:
4 We recommended that the Phoenix VA Health Care System Director assess Emergency Department medication prescription delivery practices to identify potential opportunities to improve pharmacy services.
Closure Date:
5 We recommended that the Phoenix VA Health Care System Director ensure all patients in the Radiology Department are supervised.
Closure Date:
6 We recommended that the Phoenix VA Health Care System Director assess Environmental Management Services staffing needs and take appropriate actions.
Closure Date:
7 We recommended that the Phoenix VA Health Care System Director ensure environment of care concerns identified in this report are corrected and that compliance be monitored.
Closure Date:
8 We recommended that the Phoenix VA Health Care System Director ensure Allergy Clinic staff use standard precautions when disposing used thermometer covers and that compliance be monitored.
Closure Date:
9 We recommended that the Phoenix VA Health Care System Director ensure patients receive recommended preventive medications or are offered substitutions if the medication is not on the VA National Formulary.
Closure Date:
10 We recommended that the Minneapolis VA Health Care System Director ensure that test results are communicated to patients as required.
Closure Date:
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| 16-01040-324 | Combined Assessment Program Summary Report – Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2015 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Risk Managers invite clinicians involved in Level 2 or 3 peer reviews to submit comments to and/or appear before the Peer Review Committee.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network managers, ensure Facility Directors review all privilege forms annually and document the review.
Closure Date:
3 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Medical Staff Coordinators complete the conversion from six-part to two-part credentialing and privileging folders and ensure non-allowed information is not placed in the folders.
Closure Date:
4 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that Chiefs of Surgery discuss surgical deaths with identified problems in Surgical Work Group meetings.
Closure Date:
5 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facilities designate a committee to oversee safe patient handling activities, track patient handling injury data, and share data with safe patient handling champions.
Closure Date:
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| 15-03073-275 | Review of VHA’s Alleged Manipulation of Appointment Cancellations at VAMC Houston, TX | Audit | ||
1 We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken based on the factual circumstances developed in this report regarding appointments incorrectly recorded as canceled by patient.
2 We recommended the Veterans Integrated Service Network 16 Director confers with VA’s Office of Accountability Review to determine what, if any, administrative action should be taken regarding instructions to staff to incorrectly record appointments as canceled by patient.
3 We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center provides training on when to use clinic versus patient cancellation options and how to identify the clinically indicated appointment date.
4 We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center improves scheduling audit processes to ensure that managers conduct a complete review of appointment data to ensure scheduling staff are using the correct cancellation type and clinically indicated or preferred appointment date.
Closure Date:
5 We recommended the Veterans Integrated Service Network 16 Director ensure the Director of the Michael E. DeBakey VA Medical Center makes sure managers take corrective action when audits identify deficiencies in scheduling staff’s use of appointment cancellation type and clinically indicated or preferred appointment dates.
6 We recommended the Veterans Integrated Service Network 16 Director conduct a scheduling audit within 3 months after Recommendations 3 through 5 are implemented to ensure the corrective actions taken were effective.
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15039