Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-03917-487 | Audit of VHA’s Efforts To Improve Veterans’ Access to Outpatient Psychiatrists | Audit | ||
1 We recommended the Under Secretary for Health ensure Veteran Integrated Service Networks and facilities incorporate the Office of Mental Health Operations staffing model to determine the appropriate number of psychiatrists needed for outpatient care, and work with those facilities to attain appropriate staffing levels or identify alternative options to meet veteran demand for psychiatrists.
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2 We recommended the Under Secretary for Health develop clinic management business rules to ensure facilities consistently monitor the use of clinical time and number of veterans per psychiatrist, in conjunction with monitoring psychiatrists’ productivity.
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3 We recommended the Under Secretary for Health reassess the appropriateness of the Veterans Health Administration’s productivity target for psychiatrists.
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| 15-00001-436 | Inspection of VA Regional Office St. Petersburg, Florida | Audit | ||
1 We recommended the St. Petersburg VA Regional Office Director conduct a review of the 1,717 temporary 100 percent disability evaluations remaining from our inspection universe as of October 8, 2014, and take appropriate action.
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2 We recommended the Under Secretary for Benefits direct Veterans Benefits Administration field offices prioritize processing reminder notifications within 30 days as required.
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3 We recommended the St. Petersburg VA Regional Office Director implement a plan to improve the effectiveness of the second-signature review process for special monthly compensation and ancillary benefits rating decisions
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4 We recommended the St. Petersburg VA Regional Office Director implement a plan to provide training and assess the effectiveness of that training, to ensure staff establish accurate dates of claim in the electronic systems.
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5 We recommended the St. Petersburg VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reductions cases.
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6 We recommended the Under Secretary for Benefits direct Veterans Benefits Administration field offices to prioritize benefits reductions cases in order to minimize overpayments.
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| 15-00607-483 | Combined Assessment Program Review of the San Francisco VA Health Care System, San Francisco, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers review privilege forms annually and document the review.
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2 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
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3 We recommended that Environment of Care Committee meeting minutes track open items to resolution.
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4 We recommended that Infection Control Committee meeting minutes reflect discussion of all identified high-risk areas and implementation of actions to address those areas.
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5 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
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6 We recommended that facility managers ensure personal protective equipment gowns and eyewear are readily available in all patient care areas and monitor compliance.
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7 We recommended that employees promptly remove outdated commercial supplies from sterile supply rooms and that facility managers monitor compliance.
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8 We recommended that employees promptly remove expired medications from patient care areas and that facility managers monitor compliance.
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9 We recommended that employees secure medication carts when not in use and that facility managers monitor compliance.
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10 We recommended that the facility consistently implement corrective actions for issues identified during monthly community living center medication storage area inspections and that facility managers monitor the changes until issues are fully resolved.
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11 We recommended that the facility revise the policy for safe use of automated dispensing machines to include minimum competency requirements for users and that facility managers monitor compliance.
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12 We recommended that facility managers ensure designated employees receive automated dispensing machine training and competency assessment and monitor compliance.
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13 We recommended that facility managers ensure that parenteral syringes are not used to measure oral liquid medications and monitor compliance.
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14 We recommended that computed tomography technologists perform and document quality assurance checks each weekday and that facility managers monitor compliance.
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15 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions using the required advance directive note titles and that facility managers monitor compliance.
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16 We recommended that facility managers ensure that only sharps are disposed of in sharps containers and monitor compliance.
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| 15-00152-481 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff provide education and counseling for patients with positive alcohol screens and alcohol consumption above National Institute on Alcohol Abuse and Alcoholism limits.
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2 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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3 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing and health coaching training and that providers and clinical associates in the outpatient clinics receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
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4 We recommended that clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
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5 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
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6 We recommended that the facility director ensures that the facility’s written policy for the communication of laboratory results includes all required elements.
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7 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
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| 15-00597-462 | Combined Assessment Program Review of the Northport VA Medical Center, Northport, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners' folders do not contain non-allowed information.
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2 We recommended that when conversions from observation bed status to acute admissions are 25-30 percent or more, the facility reassesses observation criteria and utilization.
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3 We recommended that the CPR Committee review each code episode.
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4 We recommended that the Surgical Work Group document its review of National Surgical Office reports.
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5 We recommended that the facility keep the recipient list for the automated Critical Incident Tracking Notification e-mail current.
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6 We recommended that the facility review the quality of entries in the electronic health record at least quarterly.
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7 We recommended that the quality control policy for scanning include a complete review of scanned documents to ensure readability and retrievability and that facility managers monitor compliance.
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8 We recommended that the facility revise the observation bed policy to reflect Veterans Health Administration policy and current practice.
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9 We recommended that the Infection Control Committee consistently document analysis of surveillance activities and data.
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10 We recommended that facility managers delegate responsibility for cleaning non-critical equipment and monitor compliance.
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11 We recommended that the facility establish a policy/procedure/guideline for the identification of individuals entering the facility and that facility manager's monitor compliance.
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12 We recommended that employees store clean and dirty items separately and that facility managers monitor compliance.
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13 We recommended that facility managers ensure that furniture in inpatient mental health patient care areas is compliant with the VA National Center for Patient Safety Mental Health Environment of Care Checklist and monitor compliance.
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14 We recommended that the facility maintain ventilation, temperature, and humidity levels in inpatient care areas according to Joint Commission and Centers for Disease Control and Prevention guidelines and VA policy to provide a safe environment for patients, staff, and visitors and that facility managers monitor compliance.
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15 We recommended that the facility establish a list of resources and assets it may need during an emergency.
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16 We recommended that the facility¿s Emergency Operations Plan include the management of a potential increase in demand for clinical services for patients who are geriatric or disabled or have serious chronic conditions or addictions and the management of mental health services during an emergency.
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17 We recommended that the facility use special medication labeling or institute unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
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18 We recommended that the facility develop and implement a process for managing and labeling high-alert medications and that facility managers monitor compliance.
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19 We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and that facility managers monitor compliance.
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20 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
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21 We recommended that the facility develop policies and procedures for managing and reviewing revised computed tomography protocols.
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22 We recommended that a medical physicist review all revised computed tomography protocols and that facility managers monitor compliance.
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23 We recommended that radiologists ensure all computed tomography reports contain the radiation dose and that facility managers monitor compliance.
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24 We recommended that Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees submit timely work orders for items needing repair and that program managers ensure deficiency correction.
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25 We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program employees perform and document contraband inspections and that program managers monitor compliance.
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26 We recommended that Substance Abuse Residential Rehabilitation Treatment Program managers ensure that the program has written agreements in place acknowledging resident responsibility for medication security.
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27 We recommended that Substance Abuse and Post-Traumatic Stress Disorder Residential Rehabilitation Treatment Program managers ensure that closed circuit television does not monitor treatment activities.
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| 15-00603-477 | Combined Assessment Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Surgical Work Group meet monthly.
Closure Date:
2 We recommended that the facility include most outpatient services in the review of electronic health record quality.
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3 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
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4 We recommended that facility managers ensure designated employees receive evacuation device training and monitor compliance.
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5 We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for all users with access to the machines.
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6 We recommended that teleradiology include radiation dose information in computed tomography summary reports and that facility managers monitor compliance.
Closure Date:
7 We recommended that employees screen inpatients to determine whether they have advance directives and document the screening using the appropriate note titles and that facility managers monitor compliance.
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8 We recommended that employees hold advance directive discussions requested by inpatients and document the discussions using the required advance directive note titles and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility ensure a clinician with emergency airway management privileges or scope of practice or an anesthesiology staff member is available during all hours the facility provides patient care and that facility managers monitor compliance.
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10 We recommended that the facility develop and grant a scope of practice that includes emergency airway management for respiratory therapists who have established competency to perform the procedure.
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| 13-03054-463 | Administrative Investigation, Improper Use of Web-based Collaboration Technology, Office of Information and Technology | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff confer with the Offices OIT, OPIA, and General Counsel (OGC) to ensure that VA Yammer is formally evaluated, approved, and/or disapproved for VA use. If approved, ensure it meets all Federal laws and regulations, as well as VA policy and guidance. If disapproved, ensure that all VA employees cannot access it from VA-issued equipment or VA's network.
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2 We recommend that the VA Chief of Staff confer with the Offices of Human Resources (OHR), Accountability Review (OAR), and OGC to determine the appropriate administrative action to take, if any, against accountable OIT and OPIA officials, as well as other VA and contractor employees involved in this particular matter.
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3 We recommend that the VA Chief of Staff ensure that all VA employees are made fully aware of which Web-based collaboration technologies VA has approved for their use and which are prohibited.
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| 15-04652-448 | Review of Alleged Shredding of Claims-Related Evidence at the VA Regional Office Los Angeles, California | Audit | ||
1 We recommend the VA Regional Office Director implement a plan to ensure the Los Angeles VA Regional Office staff comply with the Veterans Benefits Administration’s policy for handling, processing, and protection of claims-related documents.
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2 We recommend the VA Regional Office Director assess the effectiveness of the training provided to the Los Angeles VA Regional Office staff on Veterans Benefits Administration’s policy for managing veterans’ and other Governmental records.
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3 We recommend the VA Regional Office Director provide documentation to VA OIG that proper action has been taken to process the eight cases that had the potential to affect veterans’ benefits.
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| 15-00134-454 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Northport VA Medical Center, Northport, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure a clean and well maintained environment of care at the East Meadow CBOC
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2 We recommended that managers ensure review of the hazardous materials inventory occurs twice within a 12-month period at the East Meadow CBOC.
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3 We recommended that employees at the East Meadow CBOC receive the required training on hazardous materials.
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4 We recommended that hand hygiene compliance is monitored at the East Meadow CBOC and reported to the Infection Control Committee.
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5 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
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:
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days, as required by VHA.
Closure Date:
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| 15-02131-471 | Healthcare Inspection – Unexpected Death of a Patient During Treatment with Multiple Medications, Tomah VA Medical Center, Tomah, WI | Hotline Healthcare Inspection | ||
1 We recommended that the Acting Veterans Integrated Service Network Director review the care of the patient who is the subject of this report and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
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2 We recommended that the Acting Facility Director ensure compliance with VHA Handbook 1004.01, Informed Consent for Clinical Treatments and Procedures as it relates to medication administration.
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3 We recommended that the Acting Facility Director review all elements needed to respond effectively to medical emergencies including staff training, equipment, and other resources at both the unit and the facility level and take any appropriate actions.
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4 We recommended that the Acting Facility Director review and evaluate medications currently available on emergency crash carts, including but not limited to, reversal agents for narcotic and/or benzodiazepine toxicity and make changes as appropriate.
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15039