Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02890-286 | Healthcare Inspection – Alleged Improper Management of Dermatology Requests, Fayetteville VA Medical Center, Fayetteville, North Carolina | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director follow up on the 143 patients referenced in this report who did not receive dermatology care after their appointments or consults were cancelled, and take appropriate action.
Closure Date:
2 We recommended that the facility Director follow up on all the patients with cancelled dermatology appointments and consultations in 2011–2012 who were not subsequently seen by a dermatology provider to determine whether the requested evaluation and/or care is still needed.
Closure Date:
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| 15-03802-222 | Review of Alleged Lack of Audit Logs for the Veterans Benefits Management System | Audit | ||
1 We recommended the Acting Under Secretary for Benefits develop and provide the Office of Information and Technology with system requirements for integrating audit logs containing the data security officers need to intervene in potential security violations into the Veterans Benefits Management System.
Closure Date:
2 We recommended the Assistant Secretary for Information and Technology integrate audit logs into the Veterans Benefits Management System based on the requirements provided by the Acting Under Secretary for Benefits.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits test the newly integrated audit logs to ensure that the logs capture all potential security violations.
Closure Date:
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| 16-00108-274 | Combined Assessment Program Review of the Tuscaloosa VA Medical Center, Tuscaloosa, Alabama | Comprehensive Healthcare Inspection Program | ||
1 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:
2 We recommended that the facility annually assess the competency of pharmacy employees who prepare compounded sterile products and that facility managers monitor compliance.
Closure Date:
3 We recommended that facility managers ensure employees perform and document monthly cleaning of storage shelving in all compounding areas and monitor compliance.
Closure Date:
4 We recommended that the facility revisethe radiation safety policy to include a computed tomography quality control program with annual program monitoring by a medical physicist, image quality monitoring, and scanner maintenance; computed tomography protocol monitoring and a method for identifying and reporting excessive doses to the Radiation Safety Officer; a process for managing/reviewing computed tomography protocols and procedures to follow when revising protocols; and radiologist review of appropriateness of computed tomography orders.
Closure Date:
5 We recommended that facility managersconfirm computed tomography technologists have computed tomography certification prior to hiring them and ensure all current computed tomography technologists hired after July 1, 2014, have the certification.
Closure Date:
6 We recommended that the facility ensure new clinical employees complete suicide risk management training within the required timeframe and that facility managers monitor compliance.
Closure Date:
7 We recommended that clinicians consistently place flags in the electronic health records of high-risk patients and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure Focused Professional Practice Evaluations for newly hired licensed independent practitioners are reported timely to the Medical Executive Committee.
Closure Date:
9 We recommended that facility managers ensure Sterile Processing Service employees responsible for reprocessing activities receive annual competency assessments.
Closure Date:
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| 15-03581-204 | Review of Alleged Data Manipulation of Appealed Claims at VA Regional Office Wichita, Kansas | Audit | ||
1 We recommended the Wichita VA Regional Office Director ensure staff correct the 36 Notices of Disagreement established in the Veterans Appeals Control and Locator System using inaccurate data.
Closure Date:
2 We recommended the Wichita VA Regional Office Director develop and implement a plan to provide adequate oversight to ensure staff establish Notices of Disagreement in the Veterans Appeals Control and Locator System using accurate data.
Closure Date:
3 We recommended the Acting Under Secretary for Benefits develop a plan to notify staff at its 56 VA Regional Offices of the modified policy, effective July 29, 2015, to ensure correct processing of appellate claims.
Closure Date:
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| 11-00826-261 | Review of Potential Inappropriate Split Purchasing at VA New Jersey Health Care System | Audit | ||
1 We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review of VA New Jersey Health Care System purchase card transactions from December 2012 through May 2014 and require cardholders to initiate ratification for identified unauthorized commitments.
Closure Date:
2 We recommended the Interim Director of Veterans Integrated Service Network 3 develop a plan to ensure the VA New Jersey Health Care System complies with VA purchase card program policies and internal controls, to include prioritizing required annual audits of cardholder purchases and establishing service contracts when appropriate.
Closure Date:
3 We recommended the Interim Director of Veterans Integrated Service Network 3 hold VA New Jersey Health Care System purchase cardholders, supervisors, and approving officials accountable for policy violations, to include taking appropriate administrative action, if warranted.
Closure Date:
4 We recommended the Interim Director of Veterans Integrated Service Network 3 conduct a review of VA New Jersey Health Care System purchase card transactions for building renovations and take corrective action for all identified inappropriate transactions.
Closure Date:
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| 15-05154-271 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Sheridan VA Healthcare System, Sheridan, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Afton CBOC receive annual training on the Exposure Control Plan for Bloodborne Pathogens.
Closure Date:
2 We recommended that the Facility Director ensures that a policy/procedure is in place for the identification of individuals entering the Afton CBOC.
Closure Date:
3 We recommended that the clinic manager ensures that Afton CBOC employees receive the required hazardous communications training.
Closure Date:
4 We recommended that the Facility Director ensures there is a policy/procedure for the cleaning and disinfection of telehealth equipment at the Afton CBOC.
Closure Date:
5 We recommended that clinicians document assessments and treatment plans for Home Telehealth patients.
Closure Date:
6 We recommended that providers sign Home Telehealth assessments and treatment plans.
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 required by VHA.
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 acceptable providers document plans of care and disposition for patients with positive PTSD screens.
Closure Date:
11 We recommended that further diagnostic evaluations are offered to patients with positive PTSD screens.
Closure Date:
12 We recommended that providers complete diagnostic evaluations for patients with positive PTSD screens.
Closure Date:
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| 16-00112-267 | Combined Assessment Program Review of the James H. Quillen VA Medical Center, Mountain Home, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Suicide Prevention Coordinator consistently provide at least five community outreach activities every month and that facility managers monitor compliance.
2 We recommended that Domiciliary Care for Homeless Veterans Program employees consistently perform and document weekly inspections of a minimum of 10 percent of resident rooms for contraband and that program managers monitor compliance.
3 We recommended that Mental Health Residential Rehabilitation Treatment Program employees consistently perform and document daily resident room inspections for unsecured medications and that program managers monitor compliance.
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| 16-00693-269 | Combined Assessment Program Summary Report – Evaluation of Safe Medication Storage Practices in Veterans Health Administration Facilities | 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 facilities’ policies include automated dispensing machine user training and competency assessment requirements and that facility managers monitor 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 employees perform and document monthly inspections of all medication storage areas and that facility managers monitor 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 when employees identify deficiencies during medication storage area inspections, they document corrective actions and that facility managers monitor 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 facilities have oral syringes available for medication administration and clearly label and store them separately from parenteral syringes and that facility managers monitor compliance.
Closure Date:
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| 16-00017-245 | Review of Community Based Outpatient Clinic and Other Outpatient Clinics of Tuscaloosa VA Medical Center, Tuscaloosa, Alabama | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers monitor hand hygiene compliance at the Selma VA Clinic.
Closure Date:
2 We recommended that providers sign Home Telehealth assessments and treatment plans.
Closure Date:
3 We recommended that clinicians document the Home Telehealth enrollment process prior to the entry of monthly monitoring notes.
Closure Date:
4 We recommended that clinicians consistently notify patients of their laboratory results within the timeframe set by local policy.
Closure Date:
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| 15-02384-212 | Review of VBA’s Alleged Inappropriate Prioritization of Appeals at VARO Roanoke, VA | Audit | ||
1 We recommended that the Roanoke VA Regional Office Director ensure that leadership and appeals staff follow the workload management plan to prioritize work based on the appeals pending the longest.
Closure Date:
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15039