Recommendations
2124
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-01143-44 | Veteran Self-Scheduling Process Needs Better Support, Stronger Controls, and Oversight | Review | ||
1 Evaluate its Veteran Self-Scheduling training and identify improvements if they are needed.
2 Make certain that staff who are involved in the Veteran Self-Scheduling process are trained on how to assess eligibility for the scheduling option, communicate key information to veterans on the option, and conduct appropriate consult follow-up procedures.
Closure Date:
3 Ensure all guidance related to the Veteran Self-Scheduling process is clear, consistent, and disseminated to all VA medical facilities.
4 Establish a mechanism to effectively track and monitor each VA medical facility’s challenges with implementation of the Veteran Self-Scheduling process and then develop a plan to address reported issues.
Closure Date:
5 Develop best practices and lessons learned for implementing the Veteran Self‑Scheduling process and disseminate them to all VA medical facilities.
6 Develop controls to ensure VA medical facility staff have the tools in place to identify instances of potential inappropriate processing or inappropriate use of Veteran Self-Scheduling consults.
7 Direct facilities to conduct routine reviews of Veteran Self-Scheduling consults to identify potential inappropriate processing or use of the Veteran Self-Scheduling option and notify VHA’s Office of Integrated Veteran Care of instances of inappropriate use.
8 Develop a plan to accurately assess whether the Veteran Self‑Scheduling process is meeting its intended goals.
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| 24-02106-80 | Review of Community Care Utilization, Delivery of Timely Care, and Provider Qualifications at the Montana VA Healthcare System in Fort Harrison, Fiscal Year 2022 | National Healthcare Review | ||
1 The Montana VA Healthcare System Director assesses the timeliness of appointment setting for direct and community care referrals and ensures facility staff establish appointments within required time frames.
2 The Montana VA Healthcare System Director assesses the timeliness of completion of community care appointments within 90 days of requested date and acts on identified opportunities for improvement.
Closure Date:
3 The Montana VA Healthcare System Director reviews consult management practices and ensures receiving staff document scheduled appointment dates for VA direct care referrals.
Closure Date:
4 The Montana VA Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.
Closure Date:
5 The Montana VA Healthcare System Director ensures community care providers utilized by the system are designated as eligible in the Provider Profile Management System and acts on identified opportunities to improve the accuracy of eligibility designations.
Closure Date:
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| 24-00166-35 | Deficiencies in Managing Supply, Equipment, and Implant Inventory at the Michael E. DeBakey VA Medical Center in Houston, Texas | Review | ||
1 Ensure supervisors conduct monitoring activities, including periodic reviews of expendable and nonexpendable inventory and root cause analyses of identified discrepancies to strengthen controls over VA supplies.
Closure Date:
2 Establish routine monitoring for the accountable officer to verify the required use of barcode labels to track and identify supplies and equipment and report deficiencies for barcode replacement.
Closure Date:
3 Address all unaccepted equipment and establish a requirement for custodial officers to routinely accept equipment in Maximo.
Closure Date:
4 Implement a mechanism for the accountable officer to routinely monitor and ensure service‑line staff who conduct physical inventory are designated in writing by the custodial officers and receive the appropriate nonexpendable inventory training annually.
Closure Date:
5 Require the accountable officer and supply chain staff to verify and update the information in the Maximo system and create procedures to ensure all nonexpendable equipment is received through the warehouse, recorded in Maximo, delivered in a timely manner to the requesting service, and accepted by the custodial officer.
Closure Date:
6 Address the physical security issues identified and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouse.
7 Ensure all biological and nonbiological implants are recorded in the approved inventory management system and are routinely reconciled with other systems used to manage implant expiration dates.
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8 Develop controls to ensure implant program staff identify and create local agreements for existing consignment implants and establish agreements for future consignment implants in accordance with national guidance.
Closure Date:
9 Officially designate a facility implant coordinator and establish a monitoring mechanism to ensure compliance with implant coordinator roles and responsibilities.
Closure Date:
10 Update the local implant management policy to clarify roles and responsibilities and to train staff in these roles about their implant management responsibilities.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $1,200,000
Total: $1,200,000
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| 24-00551-64 | Healthcare Facility Inspection of the VA Washington DC Healthcare System | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalk between the patient parking garage and main entrance until completion.
Closure Date:
2 The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.
Closure Date:
3 The OIG recommends facility leaders implement actions to correct the electrical issue in the Emergency Department Main 2 area and mitigate the risk until it is resolved.
Closure Date:
4 The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.
Closure Date:
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| 24-02277-69 | Continued Sterile Processing Services Deficiencies and Facility Leaders’ Failures at the Carl Vinson VA Medical Center in Dublin, Georgia | Hotline Healthcare Inspection | ||
1 The Carl Vinson VA Medical Center Director ensures applicable staff, such as Sterile Processing Services staff and end users of reusable medical devices, comply with procedures regarding the identification of and disposition of nonconforming surgical instruments.
Closure Date:
2 The Carl Vinson VA Medical Center Director confirms operating room staff completes training regarding the recognition of and procedures for nonconforming surgical instruments.
Closure Date:
3 The VA Southeast Network Director establishes a comprehensive strategy to review patients who may have been affected by the approximately 800 nonconforming surgical instruments to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of disclosures.
Closure Date:
4 The VA Southeast Network Director evaluates whether administrative action is warranted for employees regarding Sterile Processing Services deficiencies at the Carl Vinson VA Medical Center, and takes action as appropriate.
Closure Date:
5 The VA Southeast Network Director provides consultation and oversight to the Carl Vinson VA Medical Center’s Sterile Processing Services to ensure implementation of facility-level action plans and sustainability of identified outcomes.
Closure Date:
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| 24-00592-60 | Healthcare Facility Inspection of the VA Dublin Healthcare System in Georgia | Healthcare Facility Inspection | ||
1 The OIG recommends that facility leaders review and correct any outdated navigational signage.
Closure Date:
2 The OIG recommends facility leaders define and assign roles and responsibilities to toxic exposure screening navigators and ensure program oversight.
Closure Date:
3 The OIG recommends the Director ensures staff keep patient care areas safe and clean.
Closure Date:
4 The OIG recommends the Director ensures biohazard storage areas display proper signage, have appropriate hand-washing supplies and equipment available, and do not contain housekeeping supplies.
Closure Date:
5 The OIG recommends the Associate Director ensures staff identify one or more facility environment of care trends and establish a performance improvement plan, including outcome measures, to address them.
Closure Date:
6 The OIG recommends that facility leaders continue to develop and implement administrative processes to ensure ordering providers promptly communicate and document test results.
7 The OIG recommends that facility leaders ensure staff maintain and reference current VHA requirements and update facility-level policies and standard operating procedures to comply with them.
Closure Date:
8 The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.
Closure Date:
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| 24-00594-61 | Healthcare Facility Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.
Closure Date:
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| 22-03076-65 | Ensuring Grantee Compliance with Veteran Care and Safety Requirements in Transitional Housing: Lessons Learned from San Diego | Administrative Investigation | ||
1 Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.
2 Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.
3 Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.
4 Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantee’s premises and any adverse health or safety inspection results or similar findings made concerning the grantee’s premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.
Closure Date:
5 Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSD’s clinical treatment housing model.
Closure Date:
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| 24-01859-62 | Mental Health Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Mental Health Inspection Program | ||
1 The VA Central Western Massachusetts Healthcare System Director establishes a mental health executive council that operates in accordance with VHA requirements.
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2 The VA Central Western Massachusetts Healthcare System Director ensures staff consistently solicit and incorporate veteran feedback into process improvements.
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3 The VA Central Western Massachusetts Healthcare System Chief of Mental Health develops written guidance to ensure staff and veteran safety during outdoor breaks.
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4 The VA Central Western Massachusetts Healthcare System Director ensures the development of written processes for the admission of veterans on an involuntary hold and monitors and tracks compliance with involuntary commitment requirements.
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5 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures timely documentation of discussions between the prescriber and veteran on the risks and benefits of newly prescribed medications and monitors for compliance.
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6 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions for veterans include follow-up appointment location and contact information in easy-to-understand language.
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7 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures discharge instructions include the purpose for each medication listed and are written in easy-to-understand language.
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8 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff complete the Columbia-Suicide Severity Rating Scale within 24 hours before discharge and monitors for compliance.
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9 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures staff address ways to make veterans’ environments safer from potentially lethal means in safety plans and monitors for compliance.
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10 The VA Central Western Massachusetts Healthcare System Director ensures staff comply with Skills Training for Evaluation and Management of Suicide requirements and monitors for compliance.
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11 The VA Central Western Massachusetts Healthcare System Director establishes an interdisciplinary safety inspection team in alignment with Veterans Health Administration requirements and ensures ongoing compliance.
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12 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures that the sally port inpatient unit doors are synchronized and monitors for compliance.
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13 The VA Central Western Massachusetts Healthcare System Director uses VHA guidelines to develop facility-specific policy for the use of restraint chairs.
Closure Date:
14 The VA Central Western Massachusetts Healthcare System Director ensures alignment between physical restraint policies and practices.
Closure Date:
15 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures mental health leaders update inpatient unit furniture to meet safety requirements and implements processes to reduce associated safety risks.
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16 The VA Central Western Massachusetts Healthcare System Chief of Staff ensures compliance with VHA requirements for Mental Health Environment of Care Checklist training completion.
Closure Date:
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| 24-01827-57 | Healthcare Inspection VISN Summary Report: Evaluation of Practitioner Credentialing and Privileging for Fiscal Years 2023 to 2024 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes solo and two-deep practitioners’ professional practice evaluations in a timely manner.
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2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network chief medical officers and facility senior leaders, ensures an external practitioner with equivalent specialized training and similar privileges completes Ongoing Professional Practice Evaluations of chiefs of staff in each facility in a timely manner.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, reviews state licensing board reporting processes at the network level to ensure compliance with Veterans Health Administration policy.
Closure Date:
4 The Under Secretary for Health, in conjunction with the Veterans Integrated Service Network 8 Director, ensures the Chief Medical Officer oversees each facility’s annual self-assessment and confirms responses reflect accurate data.
Closure Date:
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15303