Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-02952-498 | Healthcare Inspection – Quality of Care Concerns in a Diagnostic Evaluation, Jesse Brown VA Medical Center, Chicago, Illinois | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director evaluate the scheduling process for vascular consultations and diagnostic tests and take action if factors potentially impacting quality of care are identified.
2 We recommended that the Facility Director evaluate the practice of vascular laboratory technicians interpreting the urgency of providers’ consult requests and whether providers are notified when consult requests are not scheduled within the providers’ timeframe and take action if needed.
3 We recommended that the Facility Director develop a policy defining who is responsible for provider and patient notification of consults ordered through the Emergency Department or Urgent Care Clinic that are not completed timely according to Veterans Health Administration policy.
4 We recommended that the Facility Director ensure that providers perform comprehensive pain assessments according to Veterans Health Administration policy and monitor compliance.
5 We recommended that the Facility Director conduct an internal evaluation of the case discussed in this report.
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| 14-03434-530 | Review of Allegations of Inappropriately Completed Consults and Inappropriate Bonuses at the St. Louis VA Health Care System | Audit | ||
1 We recommended the Director of the St. Louis VA Health Care System ensure scheduling staff receive appropriate training and guidance on proper consult management.
Closure Date:
2 We recommended the Director of the St. Louis VA Health Care System perform a follow-up analysis and regular oversight of completed consults to ensure consults are not designated as “Complete” before the provider sees the patient.
Closure Date:
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| 15-00165-529 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of William S. Middleton Memorial Veterans Hospital, Madison, WI | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the doors to the examination rooms designated for women veterans are equipped with electronic or manual locks at the Baraboo VA Clinic.
Closure Date:
2 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
3 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:
4 We recommended that the Acting Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
5 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
6 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
7 We recommended that the Acting Facility Director ensures that the facility's written policy for the communication of laboratory results included all required elements.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as 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:
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| 15-00166-531 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Alaska VA Healthcare System, Anchorage, Alaska | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the Fairbanks CBOC.
Closure Date:
2 We recommended that staff store clean supplies separate from infectious materials at the Fairbanks CBOC.
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 receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
6 We recommended that providers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
7 We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
8 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
Closure Date:
9 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
10 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:
11 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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| 15-02997-526 | Administrative Investigation: Inappropriate Use of Position and Misuse of Relocation Program and Incentives in VBA | Administrative Investigation | ||
1 We recommended the Deputy Secretary review the Department's request and approval process for the Appraised Value Option program and make improvements as deemed appropriate.
Closure Date:
2 We recommended the Deputy Secretary review the Department’s request and approval process for temporary quarters subsistence expense allowance and make improvements as deemed appropriate.
Closure Date:
3 We recommended the Deputy Secretary consult with the Office of General Counsel to determine whether Ms. Rubens should be issued a bill of collection for $123.50 to recoup the improper reimbursements paid to her for alcoholic beverages and unauthorized meals and tips.
Closure Date:
4 We recommended the Deputy Secretary strengthen the approval process to include requiring an independent review of the Department’s Permanent Change of Station program to ensure moves and expenses are appropriate and justified.
Closure Date:
5 We recommended the Deputy Secretary require the Veterans Benefits Administration to establish policies and procedures to standardize its practices regarding annual salary increases when reassigning Senior Executives’ positions.
Closure Date:
6 We recommended the Deputy Secretary consult with the Office of General Counsel to determine whether bills of collection should be issued to recover unjustified relocation incentives paid by the Veterans Benefits Administration for Senior Executive reassignments.
Closure Date:
7 We recommended the Deputy Secretary consult with the Office of General Counsel to determine what actions may be taken to hold the appropriate Senior Officials accountable for processing and approving payments of unjustified relocation incentive payments.
Closure Date:
8 We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Rubens.
Closure Date:
9 We recommended that the Deputy Secretary consult with the Office of General Counsel to determine whether a bill of collection should be issued to Ms. Rubens to recoup the $274,019 paid for expenses related to her relocation.
Closure Date:
10 We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Graves.
Closure Date:
11 We recommended that the Deputy Secretary consult with the Office of General Counsel to determine whether a bill of collection should be issued to Ms. Graves to recoup the $129,468 paid for expenses related to her relocation.
Closure Date:
12 We recommended the Deputy Secretary confer with the Office of Human Resources and Administration, the Office of Accountability Review, and the Office of General Counsel to determine the appropriate administrative action to take, if any, against Ms. Hickey, Mr. Pummill, and Ms. McCoy.
Closure Date:
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| 14-04945-413 | Review of Alleged Data Sharing Violations at VA's Palo Alto Health Care System | Audit | ||
1 We recommended the VA Assistant Secretary for Information and Technology take action to ensure the Palo Alto Health Care System Information Security Officers conduct a risk assessment of Kyron software to identify potential risks, vulnerabilities, and threats to VA systems and sensitive information.
Closure Date:
2 We recommended the VA Assistant Secretary for Information and Technology implement appropriate controls to ensure that unauthorized software is not procured or installed on VA networks without a formal risk assessment and approval to operate.
Closure Date:
3 We recommended the Palo Alto Health Care System Management, in conjunction with VA’s Assistant Secretary for Information and Technology, ensure Kyron personnel receive commensurate background investigations and obtain formal authorization to operate Kyron software on VA networks.
Closure Date:
4 We recommended the Palo Alto Health Care System Management, in conjunction with VA’s Assistant Secretary for Information and Technology, require Kyron personnel to complete security awareness training and sign the Contractor Rules of Behavior to ensure full awareness of VA information security requirements when accessing VA systems and networks.
Closure Date:
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| 15-00619-515 | Combined Assessment Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed
practitioners who perform emergency airway management have the appropriate training.
Closure Date:
2 We recommended that the Surgical Work Group meet monthly.
Closure Date:
3 We recommended that facility managers ensure all health care
occupancy buildings have at least one fire drill per shift per quarter and monitor compliance.
Closure Date:
4 We recommended that facility managers ensure negative air
pressure systems in the medicine primary care clinic are functional and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure locked mental
health unit stationary panic alarm testing includes documentation of VA Police response time.
Closure Date:
6 We recommended that equipment on the locked mental health
unit is secured and heavy enough to prevent it from being picked up, thrown, moved, or overturned.
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 employees hold advance directive discussions requested by inpatients and document the discussions and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required subject matter content elements and that facility managers monitor compliance.
Closure Date:
10 We recommended that the facility revise the local policy for out of operating room emergency airway management to include successful demonstration of all required procedural skills on airway simulators for providers seeking renewal of privileges.
Closure Date:
11 We recommended that the facility document the review of provider-specific emergency airway management data in Cardiopulmonary Review Committee meeting minutes.
Closure Date:
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| 15-01996-503 | Inspection of VA Regional Office Honolulu, Hawaii | Review | ||
1 We recommended the Honolulu VA Regional Office Director provide training on traumatic brain injury claims and assess the effectiveness of that training.
2 We recommended the Honolulu VA Regional Office Director ensure frequent refresher training for processing higher levels of special monthly compensation and ancillary benefits claims and monitor the effectiveness of this training.
3 We recommended the Honolulu VA Regional Office Director strengthen the review process for higher levels of special monthly compensation and ancillary benefits claims.
4 We recommended the Honolulu VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
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| 14-02666-456 | Review of Land Purchase for the Replacement Hospital in Louisville, Kentucky | Audit | ||
1 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction establish formal VA policy and procedures regarding review appraisals and ensure its dissemination.
Closure Date:
2 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction establish an internal review board to enforce compliance with Federal laws and VA policies governing VA land purchases.
Closure Date:
3 We recommended the Principal Executive Director, Office of Acquisition, Logistics, and Construction determine the appropriate administrative actions to take for noncompliance with regulations.
Closure Date:
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| 15-00153-508 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the information technology server closet at the Belmont County VA Clinic is maintained according to information technology safety and security standards.
Closure Date:
2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
3 We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
5 We recommended that 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 clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
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15039