Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-05075-447 | Healthcare Inspection – Patient Care Deficiencies and Mental Health Therapy Availability, Overton Brooks VA Medical Center, Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure patients are notified and re-assigned timely when their mental health providers leave the facility.
Closure Date:
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| 14-04816-72 | Review of Alleged Problems With VBA’s Veterans Benefits Management System and Claims Processing | Audit | ||
1 We recommended the Under Secretary for Benefits ensure that the St. Petersburg VA Regional Office is consistently organizing and mailing hard copy veteran material to contractor scanning facilities and hold the Regional Office Director accountable for compliance.
Closure Date:
2 We recommended the Under Secretary for Benefits initiate onsite reviews of the CACI contractor scanning facilities to ensure the timely processing and the proper storage of VA sensitive information at those facilities.
Closure Date:
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| 15-00827-68 | Healthcare Inspection – Poor Follow-Up Care and Incomplete Assessment of Disability, VA San Diego Healthcare System San Diego, California | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health ensure that Compensation & Pension examiners document that patients with new diagnoses are counseled on the need for follow up care and provided assistance in obtaining VA care.
Closure Date:
2 We recommended that the Under Secretary for Health develop guidance on what clinical information from secure messaging and My HealtheVet must be documented in the EHR.
Closure Date:
3 We recommended that the System Director implement processes to ensure that providers adhere to the VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain, including follow up assessment at appropriate intervals, when treating patients with chronic opioid therapy.
Closure Date:
4 We recommended that the System Director confer with Regional Counsel for possible disclosure(s) to the surviving family member(s) of the patient.
Closure Date:
5 We recommended that the VA Regional Office San Diego Director review a sample of the specific rater’s work and determine whether failure to obtain relevant service treatment records is a systemic issue with this rater when making compensation claim decisions.
Closure Date:
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| 15-00268-66 | Healthcare Inspection – Eye Care Concerns, Eastern Kansas Health Care System, Topeka and Leavenworth, Kansas | Hotline Healthcare Inspection | ||
1 We recommended that the Eastern Kansas Health Care System Director ensure all system staff use only approved wait lists for scheduling cataract surgeries as required by Veterans Health Administration Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures, June 2010.
2 We recommended that the Eastern Kansas Health Care System Director ensure that providers use the consultation package in the Computerized Patient Records System for all eye care referrals as required by VHA Handbook 1121.01, VHA Eye Care, March 10, 2011.
3 We recommended that the Eastern Kansas Health Care System Director take actions to increase ophthalmologists’ productivity.
4 We recommended that the Eastern Kansas Health Care System Director explore and implement measures to improve communication, interpersonal dynamics, and operations within and between both Eye Clinics.
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| 15-04699-65 | Combined Assessment Program Review of the Royal C. Johnson Veterans Memorial Medical Center, Sioux Falls, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility revise its policy for patient discharge to include scheduling discharges early in the day.
Closure Date:
2 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:
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| 15-00178-56 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Louis A. Johnson VA Medical Center, Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect patient-identifiable information on laboratory specimens at the Monongalia County VA Clinic.
Closure Date:
2 We recommended that the information technology server closet at the Monongalia County VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
3 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
4 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
5 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that the Facility Director develops policies and procedures that facilitate human immunodeficiency virus testing as part of routine medical care for patients.
Closure Date:
7 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
8 We recommended that the Facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
Closure Date:
9 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-00614-64 | Combined Assessment Program Review of the Oklahoma City VA Health Care System, Oklahoma City, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that credentialing and privileging folders do not contain non-allowed information.
2 We recommended that facility managers ensure patient care areas are clean and bathrooms are free from offensive odors and monitor compliance.
3 We recommended that facility managers initiate corrective actions to repair the ceiling leak in the operating room supply area.
4 We recommended that employees secure sensitive patient information at all times and that facility managers monitor compliance.
5 We recommended that the facility annually review the look-alike and sound-alike medication list.
6 We recommended that the facility develop a written policy for the safe use of automated dispensing machines and implement the policy and that facility managers monitor compliance.
7 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
8 We recommended that consultants consistently link consult responses to the requests and that facility managers monitor compliance.
9 We recommended that the Radiation Safety Officer ensure all computed tomography technologists have documented training on safe procedures for operating the types of computed tomography equipment they use.
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| 15-04986-42 | Inspection of VA Regional Office Hartford, CT | Review | ||
1 We recommended the Hartford VA Regional Office Director conduct a review of the three temporary 100 percent disability evaluations remaining from our inspection universe as of August 11, 2015, and take appropriate action.
Closure Date:
2 We recommended the Hartford VA Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-00181-53 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Salem VA Medical Center, Salem, Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
2 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
Closure Date:
3 We recommended that providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
5 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-00175-50 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Charles George VA Medical Center, Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
2 We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
3 We recommended that managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
Closure Date:
4 We recommended 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 providers in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
7 We recommended that the Facility Director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
Closure Date:
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15039