Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00545-343 | Review of Alleged Mismanagement of VHA's Service-Oriented Architecture Research and Development Pilot Project | Audit | ||
1 We recommended the Under Secretary for Health establish an oversight mechanism to ensure the use of proper appropriations for Veterans Health Administration information technology projects.
Closure Date:
2 We recommended the Under Secretary for Health remedy all Medical Support and Compliance appropriations used to pay for Service-Oriented Architecture Research and Development.
Closure Date:
3 We recommended the Under Secretary for Health confer with VA’s Office of Accountability Review regarding administrative actions against Veterans Health Administration senior officials, beyond those individuals who have left VA employment, who were involved with Service-Oriented Architecture Research and Development funding decisions and ensure that action is taken, if appropriate.
Closure Date:
4 We recommended the Executive in Charge, Office of Information and Technology, obtain Chief Financial Officer certifications from responsible VA Administrations or Staff Offices that proper appropriations will be used before using any non-Information Technology Systems appropriations for any information technology project, including projects managed by the Project Management Accountability System.
Closure Date:
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| 15-00139-451 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Mann-Grandstaff VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 We recommended that panic buttons are tested and that testing is documented at the Wenatchee Community Based Outpatient Clinic.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
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 the Facility Director identifies a Lead Human Immunodeficiency Virus Clinician to carry out required responsibilities.
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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| 14-04983-412 | Inspection of VA Regional Office Cleveland, Ohio | Review | ||
1 We recommended the Cleveland VA Regional Office Director conduct a review of the 880 temporary 100 percent disability evaluations remaining from their universe as of October 8, 2014, and take appropriate actions.
Closure Date:
2 We recommended the Cleveland VA Regional Office Director provide training on prioritizing temporary 100 percent disability evaluation claims and assess the effectiveness of that training.
Closure Date:
3 We recommended the Cleveland VA Regional Office Director certify that corrective action has been accomplished for the seven cases still requiring action from our September 2012 inspection.
Closure Date:
4 We recommended the Cleveland VA Regional Office Director implement a plan to monitor the effectiveness of training on traumatic brain injury claims.
Closure Date:
5 We recommended the Cleveland VA Regional Office Director implement a plan to ensure staff comply with Veterans Benefits Administration's second-signature requirements for traumatic brain injury claims, including tracking and trending errors in processing to identify local training needs.
Closure Date:
6 We recommended the Cleveland VA Regional Office Director implement a plan to assess the effectiveness of the recent special monthly compensation training and continue to provide refresher training on higher levels of special monthly compensation and ancillary benefits.
Closure Date:
7 We recommended the Cleveland VA Regional Office Director implement a plan to provide refresher training to staff on establishing accurate dates of claim in the Veterans Benefits Administration's electronic systems of record and assess the effectiveness of the training.
Closure Date:
8 We recommended the Cleveland VA Regional Office Director implement a plan to ensure staff establish accurate dates of claim in the Veterans Benefits Administration's electronic systems of record.
Closure Date:
9 We recommended the Cleveland VA Regional Office Director implement a plan to ensure oversight and prioritization of benefits reduction cases.
Closure Date:
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| 15-01579-457 | Healthcare Inspection – Review of the Operations and Effectiveness of VHA Residential Substance Use Treatment Programs | National Healthcare Review | ||
1 We recommended that Mental Health Services liaison with internal and external entities regarding standardized data collection from screening processes to core outcome measures to improve program monitoring and by which Mental Health Services can develop collaborative treatment initiatives.
Closure Date:
2 We recommended that Mental Health Services ensure system-wide use of the 596 stop code.
Closure Date:
3 We recommended that Mental Health Services review the consistency of current processes and provides specific guidance on reducing inflow of contraband into residential substance use treatment programs.
Closure Date:
4 We recommended that Mental Health Services consider requiring programs to document patients' physical status in addition to presence when completing physical bed checks.
Closure Date:
5 We recommended that Mental Health Services clarify the intent of the requirement for and use of closed circuit television with respect to residential substance use programs.
Closure Date:
6 We recommended that Mental Health Services review and evaluate whether reversal agents such as naloxone are readily available at each residential substance use treatment program.
Closure Date:
7 We recommended that Mental Health Services encourage more widespread incorporation of programming with a specialized focus on mental health comorbidities.
Closure Date:
8 We recommended that Mental Health Services encourage discussion of addiction focused pharmacotherapy with residential substance use treatment program patients.
Closure Date:
9 We recommended that Mental Health Services ensure that active mental health comorbidities are addressed in residential substance use rehabilitation treatment program interdisciplinary treatment plans.
Closure Date:
10 We recommended that Mental Health Services ensure documentation of post-discharge aftercare appointment arrangements for mental health comorbidities.
Closure Date:
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| 14-04530-414 | Healthcare Inspection – Mental Health-Related Deficiencies and Inadequate Leadership Responsiveness, Central Alabama VA Health Care System, Montgomery, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Central Alabama VA Health Care System Director ensure adequate mental health staffing in the community based outpatient clinics to provide timely and appropriate patient care.
2 We recommended that the Central Alabama VA Health Care System Director ensure appropriate review and scheduling of patients on the electronic wait list and Recall Reminder lists provided to management.
3 We recommended that the Central Alabama VA Health Care System Director ensure that staff are trained on the proper use and management of the electronic wait list and the Recall Reminder list, that recall reminder letters are sent to patients, and that compliance is monitored.
4 We recommended that the Central Alabama VA Health Care System Director ensure that clinical staff and the Suicide Prevention program staff follow guidelines on the identification, tracking, treatment, and follow-up of patients at high risk for suicide.
5 We recommended that the Central Alabama VA Health Care System Director ensure that Substance Abuse Treatment Program patients have more timely access to residential/domiciliary beds, as needed.
6 We recommended that the Central Alabama VA Health Care System Director ensure that staff receive appropriate training on the policy requirements for managing disruptive behavior.
7 We recommended that the Central Alabama VA Health Care System Director ensure that the Disturbed Behavior Committee complies with policy on completing and documenting incident/threat assessments and initiating Patient Record Flags.
8 We recommended that the Central Alabama VA Health Care System Director ensure that all Disturbed Behavior Committee Alert Notes, both recent and remote, have been reviewed and appropriate actions taken, if indicated.
9 We recommended that the Central Alabama VA Health Care System Director ensure behavioral Patient Record Flags are re-evaluated within established timeframes.
10 We recommended that the Central Alabama VA Health Care System Director evaluate options available to improve the timeliness of Emergency Department clearance and acute mental health unit admission for high risk patients.
11 We recommended that the Central Alabama VA Health Care System Director ensure that mental health providers adequately document their clinical reasoning when their treatment decisions do not comply with VA/DoD guidelines for medication management in Post-Traumatic Stress Disorder and Substance Use Disorder patients.
Closure Date:
12 We recommended that the Central Alabama VA Health Care System Director approve and issue a Mental Health Treatment Coordinator policy and train appropriate staff on same.
13 We recommended that the Central Alabama VA Health Care System Director ensure assignment of Mental Health Treatment Coordinators for all appropriate patients.
Closure Date:
14 We recommended that the Central Alabama VA Health Care System Director monitor to ensure the Dothan Primary Care contractor complies with staffing and care specifications as outlined in the contract.
15 We recommended that the Central Alabama VA Health Care System Director ensure that the Dothan Primary Care contract complies with Veterans Health Administration policy on the treatment of uncomplicated psychiatric disorders.
16 We recommended that the Central Alabama VA Health Care System Director update the Dothan Mental Health Community Based Outpatient Clinics recorded message to instruct callers on what to do for a mental health emergency and how to access the Suicide Prevention/Crisis lines.
17 We recommended that the Central Alabama VA Health Care System Director reinitiate ongoing professional practice evaluation-related mental health chart reviews.
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| 14-04530-452 | Healthcare Inspection - Deficient Consult Management, Contractor, and Administrative Practices, Central Alabama VA Health Care System, Montgomery, Alabama | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health provide consistent interim leadership to Central Alabama Veterans Health Care System in the form of highly skilled leaders who can lead systemic improvements and cultural change until such time as the leadership positions can be filled permanently.
Closure Date:
2 We recommended that the Under Secretary for Health directly monitor corrective actions taken to remedy the deficiencies identified in this report and routinely assess their effectiveness at least annually for a period of 3 years.
Closure Date:
3 We recommended that interim Central Alabama Veterans Health Care System leadership begin, and permanent leadership continue, to make systemic improvements to the Non-VA Care Coordination consult process, to include ensuring that patients receive services timely; that the backlog is resolved; that staff comply with business rules governing the process; and that the program is provided with adequate staffing, training, and a consistent leadership structure.
Closure Date:
4 We recommended that the interim Central Alabama Veterans Health Care System leadership develop processes to ensure that Human Resource tracking and reporting is accurate and that Central Alabama Veterans Health Care System either has adequate staffing to meet patient care needs in a timely manner or adequate processes to ensure patients receive timely care in the community.
Closure Date:
5 We recommended that the interim Central Alabama Veterans Health Care System leadership identify opportunities to improve system integration between the Montgomery campus, the Tuskegee campus, and the community based outpatient clinics, to include evaluating the need for dedicated community based outpatient clinic coordinators.
Closure Date:
6 We recommended that the interim Central Alabama Veterans Health Care System leadership ensure that the system Administrative Boards of Investigation policy reflects all required elements outlined in the Veterans Health Administration Handbook.
Closure Date:
7 We recommended that the interim Central Alabama Veterans Health Care System leadership ensure that all previously chartered Administrative Boards of Investigations have been conducted and finalized to include documentation of decision for final action(s), evidence that actions have been implemented and/or addressed, and appropriate certification of completion per Veterans Health Administration guidelines.
Closure Date:
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| 15-01193-433 | Inspection of VA Regional Office Louisville, Kentucky | Review | ||
1 We recommended the Louisville VA Regional Office Director develop and implement a plan to ensure staff follows policies and procedures associated with scheduling medical reexaminations.
Closure Date:
2 We recommended the Louisville VA Regional Office Director conduct a review of the 345 temporary 100 percent disability evaluations remaining from our inspection universe as of December 10, 2014, and take appropriate action.
Closure Date:
3 We recommended the Louisville VA Regional Office Director develop and implement a plan to assess the effectiveness of higher-level Special Monthly Compensation training.
Closure Date:
4 We recommended the Louisville VA Regional Office Director develop and implement a plan to assess the accuracy of secondary reviews involving higher-level Special Monthly Compensation and ancillary benefits.
Closure Date:
5 We recommended the Louisville VA Regional Office Director implement a plan to ensure staff timely process claims related to benefits reductions to minimize improper payments to veterans.
Closure Date:
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| 15-00599-438 | Combined Assessment Program Review of the Mann-Grandstaff VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate privileges.
Closure Date:
2 We recommended that the Critical/Acute Care and Transfusion Committee review each code episode, that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code, and that the committee collects code data.
Closure Date:
3 We recommended that the Surgical Quality Committee meet monthly, document its review of National Surgical Office reports, and review all surgical deaths with identified problems or opportunities for improvement.
Closure Date:
4 We recommended that the facility keep the recipient list for the critical incident automated e-mail notification current.
Closure Date:
5 We recommended that the recently initiated Accident Review Board provide oversight of the safe patient handling program and gather, track, and share patient handling injury data.
Closure Date:
6 We recommended that the quality control policy for scanning include the quality of the source document, an alternative means of capturing data when the quality of the source document does not meet image quality controls, a correction process if scanned items have errors, and a complete review of scanned documents to ensure readability and retrievability.
Closure Date:
7 We recommended that Environment of Care Committee meeting minutes track actions taken in response to identified deficiencies to closure.
Closure Date:
8 We recommended that facility managers ensure fire extinguishers in all patient care areas have documented monthly safety checks and monitor compliance.
Closure Date:
9 We recommended the facility complete and document an annual review of the Hazard Vulnerability Assessment.
Closure Date:
10 We recommended that facility managers ensure that oral syringes are available for liquid medications on all nursing units and that they are stored separately from parenteral syringes to minimize the risk of wrong-route medication errors.
Closure Date:
11 We recommended that nursing reviewers sign the monthly medication inspection forms for the intensive care and inpatient general medicine units and that facility managers monitor compliance.
Closure Date:
12 We recommended that requestors consistently select the proper consult title and that facility managers monitor compliance.
Closure Date:
13 We recommended that consultants consistently complete inpatient consults within the specified timeframe and that facility managers monitor compliance.
Closure Date:
14 We recommended that employees consistently post patients’ advance directives status correctly and that facility managers monitor compliance.
Closure Date:
15 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed for employees on the intensive care unit.
Closure Date:
16 We recommended that the facility revise the emergency airway management policy to include the type of clinical staff whose expected duties would include emergency airway management.
Closure Date:
17 We recommended that the facility ensure initial clinician emergency airway management competency assessment includes all required components and that facility managers monitor compliance.
Closure Date:
18 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.
Closure Date:
19 We recommended that facility managers ensure video laryngoscopes are available for immediate clinician use and monitor compliance.
Closure Date:
20 We recommended that the facility ensure that actions from peer reviews are consistently completed and reported to the Peer Review Committee.
Closure Date:
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| 15-00533-440 | Healthcare Inspection – Delay in Emergency Airway Management and Concerns about Support for Nurses, VA Northern California Health Care System, Mather, CA | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that staff provide patients information on and assistance with completing advance directives.
Closure Date:
2 We recommended that the Facility Director ensure that corrective action plans concerning clinical warnings, including code status, on patients' wristbands are fully implemented and that managers monitor compliance.
Closure Date:
3 We recommended that the Facility Director instruct nurse managers to conduct an inspection and ongoing monitoring of all inpatient units to ensure nurses do not make copies of wristbands for medication administration.
Closure Date:
4 We recommended that the Facility Director conduct an evaluation of the medical-surgical unit to determine if there are issues undermining psychological safety at the work place and take action to address those issues.
Closure Date:
5 We recommended that the Facility Director develop and implement a plan for employee support following traumatic events.
Closure Date:
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| 15-00130-432 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | 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 Kenosha CBOC.
Closure Date:
2 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
3 We recommended that Clinic Registered Nurse Care Managers and providers 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 document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
6 We recommended that clinicians consistently notify patients of their laboratory results within 14 days as required by VHA.
Closure Date:
7 We recommended that clinicians consistently document in the electronic health record all attempts to communicate with the patients regarding their abnormal laboratory results.
Closure Date:
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15039