Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00160-212 | Deficiencies in Informed Consent for Admission and Against Medical Advice Discharge Processes for a Patient at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director develops a process consistent with Veterans Health Administration Directive 1004.01(3) to ensure patients are informed, prior to voluntary admission to the inpatient mental health unit, that the unit is locked and provides services to patients with mental health disorders.
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2 The VA Southern Nevada Healthcare System Director ensures staff are educated following development of the informed consent process for voluntary admission to the inpatient mental health unit.
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3 The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 adheres to Nevada state law relevant to admission to mental health units and is approved in accordance with Veterans Health Administration policies.
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4 The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 includes the responsible owners’ oversight and guidance responsibilities as required by Veterans Health Administration Directive 0999(1).
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5 The VA Southern Nevada Healthcare System Director ensures staff education regarding changes to the medical center policy 116-22-10.
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6 The VA Southern Nevada Healthcare System Director ensures that any facility policies involving state law addressing voluntary or involuntary mental health commitments be reviewed by the Office of General Counsel.
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7 The VA Southern Nevada Healthcare System Director develops a process to ensure facility policies adhere to the Veterans Health Administration Directive 0999(1), medical center policy standardized template.
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| 23-01601-208 | Insufficient Mental Health Treatment and Access to Care for a Patient and Review of Administrative Actions in Veterans Integrated Service Network 10 | Hotline Healthcare Inspection | ||
1 The Ann Arbor VA Medical Center Director conducts a full review of the patient’s spring to fall 2017 mental health care to identify quality of care improvement opportunities related to inpatient psychiatrist 2’s medical decision-making, staff’s pre-discharge outpatient care planning, and outpatient staff’s collaboration in providing treatment and engagement efforts including the mental health treatment coordinator assignment and role, and takes actions as warranted.
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2 The Battle Creek VA Medical Center Director ensures staff awareness and access to eligibility verification procedures.
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3 The Battle Creek VA Medical Center Director expedites the full implementation of the Transfer and Admission Coordination Office including a centralized phone number and monitors compliance with the standardized checklist.
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4 The Battle Creek VA Medical Center Director expedites the completion and implementation of the interfacility transfers standard operating procedure and monitors compliance.
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5 The Battle Creek VA Medical Center Director ensures the mental health residential rehabilitation treatment program standard operating procedure is aligned with Veterans Health Administration requirements regarding referral and monitors compliance.
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6 The Veterans Integrated Service Network Director evaluates the efficacy of the Interagency Resolution Council and identification of clearly defined objectives and processes to monitor progress and address identified barriers.
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| 23-00776-207 | Delays and Deficiencies in the Mental Health Care of a Patient at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The VA Houston Health Care System Director evaluates the efficiency of evidence-based psychotherapy consult management procedures; identifies barriers to timely appointment scheduling, including scheduling processes and staffing needs; and takes action as warranted.
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2 The VA Houston Health Care System Director ensures that administrative support staff document scheduling efforts in patients’ electronic health records, as required by the Veterans Health Administration.
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3 The VA Houston Health Care System Director ensures that staff document offering VA-issued devices for participation in virtual mental health appointments in patients’ electronic health records.
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4 The VA Houston Health Care System Director conducts a review of providers’ lethal means safety assessment and planning with the patient, identifies barriers to effective lethal means safety discussions, and takes action as warranted.
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5 The Under Secretary for Health clarifies the expectations and requirements for homeless program staff’s completion of suicide risk assessments and updates or reviews of safety plans for high risk for suicide patients.
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6
The VA Houston Health Care System Director reviews staff’s compliance with high-risk flag patient care requirements, to include updating and reviewing safety plans, following up on failed contacts, and completing suicide risk assessments.
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| 23-03159-204 | Inadequate Care of a Patient Who Died by Suicide on a Medical Unit at the Sheridan VA Medical Center in Wyoming | Hotline Healthcare Inspection | ||
1 The Sheridan VA Medical Center Director ensures completion of warm handoffs and Comprehensive Suicide Risk Evaluations within 24 hours for patients on the medical unit that screen positive on the Columbia-Suicide Severity Rating Scale.
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2 The Sheridan VA Medical Center Director ensures that psychiatry or medical officer of the day staff reassess suicidal patients prior to changing a one-to-one observation status order.
3 The Sheridan VA Medical Center Director ensures that inpatient notes are completed and authenticated by providers as soon as possible, but always within 24 hours, in accordance with facility policy.
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4 The Sheridan VA Medical Center Director ensures that staff follow facility policies for removing belongings and environmental risks for suicidal patients on one-to-one observation status on the medical unit.
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| 23-02958-203 | Care Concerns and Deficiencies in Facility Leaders’ and Staff’s Responses Following a Medical Emergency at the Carl T. Hayden VA Medical Center in Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System rapid response policy is in alignment with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.
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2 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policies and procedures related to responding to medical emergencies do not conflict.
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3 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policy is in alignment with Veterans Health Administration Directive 1101.14, Emergency Medicine.
4 The Phoenix VA Health Care System Director ensures layperson cardiopulmonary resuscitation training is offered in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.
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5 The Phoenix VA Health Care System Director determines the need for, and implements placement of, public access automated external defibrillators in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation
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6 The Phoenix VA Health Care System Director assesses outpatient clinic compliance with vital sign completion and documentation, identifies deficiencies, and takes action as warranted.
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7 The Phoenix VA Health Care System Director reviews and assesses the need for non-clinical staff training on the use of the Joint Patient Safety Reporting system, and takes action as warranted.
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8 The Phoenix VA Health Care System Director ensures complaints are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.
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9 The Phoenix VA Health Care System Director reviews organizational communication channels and ensures consistency with Veterans Health Administration high reliability organization principles and I CARE values
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10 The Phoenix VA Health Care System Director makes certain that investigation and closure of events placed into the Joint Patient Safety Reporting system are completed per the Veterans Health Administration’s established time frame, and monitors compliance.
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| 23-00995-211 | Mismanaged Surgical Privileging Actions and Deficient Surgical Service Quality Management Processes at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director conducts focused clinical care reviews in accordance with Veterans Health Administration requirements, and monitors for compliance.
2 The Hampton VA Medical Center Director ensures that summary suspensions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.
3 The Hampton VA Medical Center Director confirms that proposed reduction or revocation of privileges complies with Veterans Health Administration policies and procedures, and monitors for compliance.
4 The Hampton VA Medical Center Director complies with Veterans Health Administration requirements when reporting licensed independent practitioners to state licensing boards.
5 The Hampton VA Medical Center Director completes a review of Medical Executive Committee meeting minutes and ensures recommendations made for focused professional practice evaluations for cause for licensed independent practitioners have been completed according to Veterans Health Administration requirements.
6 The Hampton VA Medical Center Director ensures that, when providers are transitioned from an initial focused professional practice evaluation to an ongoing professional practice evaluation, the transition is reported and documented as required by Veterans Health Administration policy, and monitors for compliance.
7 The Hampton VA Medical Center Director ensures that ongoing professional practice evaluations include documentation of all conclusionary outcomes required by Veterans Health Administration policy.
8 The Hampton VA Medical Center Director ensures surgical staff have an understanding of Veterans Health Administration Joint Patient Safety Reporting submissions and tracks submissions specific to Surgical Service, and monitors for compliance.
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9 The Hampton VA Medical Center Director completes a comprehensive review of surgical morbidity and mortality conferences and ensures facility policy and practice is in alignment with Veterans Health Administration policy and, as necessary, consults with Veterans Health Administration’s National Surgery Office and Veterans Integrated Service Network leaders, and monitors for compliance.
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10 The Hampton VA Medical Center Director ensures that the chief of surgery has a process to identify potential cases for peer review and communicates those cases to the appropriate program staff.
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11 The Mid-Atlantic Veterans Integrated Service Network Director confirms the Hampton VA Medical Center Director ensures that management reviews and peer reviews, if both indicated for the same incident of care, are conducted in accordance with Veterans Health Administration policy, and are not conducted concurrently.
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12 The Hampton VA Medical Center Director considers seeking guidance from the Office of General Counsel to determine the appropriate time frame for ensuring all required elements for previously completed institutional disclosures have been met.
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| 23-01772-162 | VBA Needs to Improve the Accuracy of Decisions for Total Disability Based on Individual Unemployability | Review | ||
1 Update guidance mandating use of an effective date builder for rating veterans service representatives to consider earlier effective dates when granting entitlement to individual unemployability.
2 Develop standardized language and prioritize incorporation into the Veterans Benefits Management System to assist rating veterans service representatives in addressing all required information/elements within an individual unemployability rating narrative.
3 Establish additional system controls to ensure rating veterans service representatives address competency when individual unemployability has been awarded based solely on a mental condition.
4 Update the Veterans Benefits Administration’s procedures manual to ensure consistency among staff and clarify the language needed to satisfy the analysis requirement when granting entitlement to individual unemployability benefits.
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5 Develop practical learning exercises for rating veterans service representatives related to individual unemployability for Virtual and In-Person Progression training.
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6 Require rating veterans service representatives and veterans service representatives to process and demonstrate individual unemployability claim competency on veterans’ claims.
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7 Evaluate the workload distribution methods for individual unemployability claims to increase claims processing consistency and knowledge retention.
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| 23-01773-166 | Better Collection of Family Preference Data May Minimize Risk of Burial Scheduling Delays | Audit | ||
1 Implement controls to allow for the capability to identify and monitor potential scheduling delays and to ensure family preferences are being met at national cemeteries.
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| 23-00151-117 | Lessons Learned for Improving the Integrated Financial and Acquisition Management System’s Acquisition Module Deployment | Review | ||
1 For future acquisitions that involve stakeholders from multiple offices, establish governance to ensure all relevant administrations and staff offices are represented in key decision roles.
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2 For future acquisitions, establish and implement a process to promote stakeholders’ understanding of system capabilities and support buy-in.
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3 Complete the hiring actions necessary to staff the Office of Acquisition and Logistics Project Management Office.
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4 Resolve key Integrated Financial and Acquisition Management System challenges and ongoing concerns identified by officials from the Office of Acquisition, Logistics, and Construction and the Office of Acquisition and Logistics before further deployment of the acquisition module.
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| 23-02898-195 | Noncompliance with Suicide Prevention Policies at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 The Overton Brooks VA Medical Center Director ensures the suicide prevention team utilizes information from Medora and the required Veterans Health Administration screening and evaluation tools when assessing patients’ suicide risk in response to Veterans Crisis Line requests, and monitors for compliance.
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2 The Overton Brooks VA Medical Center Director ensures the suicide prevention team follows national requirements for documenting each contact attempt in a patient’s electronic health record when responding to Veterans Crisis Line requests, and monitors for compliance.
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3 The Overton Brooks VA Medical Center Director ensures the suicide prevention program manager documents clinical case reviews of suicide prevention staff members’ Veterans Crisis Line request responses and addresses identified deficiencies as required by the Veterans Health Administration.
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4 The Overton Brooks VA Medical Center Director monitors intensive care unit one-to-one observation staff assignments for compliance with facility policy, and takes action as appropriate.
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5 The Overton Brooks VA Medical Center Director ensures the provision of mental health appointments for patients with a high risk for suicide patient record flag as required by Veterans Health Administration policy, and monitors for compliance.
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6 The Overton Brooks VA Medical Center Director ensures that suicide prevention staff consult with patients’ treatment teams prior to inactivation of high risk for suicide patient record flags, and monitors for compliance.
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7 The Overton Brooks VA Medical Center Director ensures timely completion of behavioral health autopsy program chart reviews and family interview contact forms, and monitors for compliance.
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8 The Veterans Integrated Service Network Director takes steps to ensure that suicide prevention positions are posted and continues to identify additional recruitment opportunities for suicide prevention positions, as indicated.
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14921