Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00112-338 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Puget Sound Health Care System, Seattle, Washington | 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 North Olympic Peninsula 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 receive motivational interviewing and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 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:
5 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:
6 We recommended that the Facility Director defines the requirements for communication of human immunodeficiency virus test results.
Closure Date:
7 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
| ||||
| 15-00126-342 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Boston Healthcare System, Boston, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Causeway VA Clinic to the parent facility.
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 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:
| ||||
| 14-03380-356 | FY 2014 Review of VA’s Compliance With the Improper Payments Elimination and Recovery Act | Audit | ||
1 We recommended the Interim Under Secretary for Health ensure implementation of the revised sampling plan for the Civilian Health and Medical Program of the Department of Veterans Affairs to address sample outliers and adjust the program¿s reduction target to a reasonably achievable level, if necessary.
Closure Date:
2 We recommended the Under Secretary for Benefits monitor the results of the Veterans Benefits Administration¿s revised testing plans for the Compensation, Pension, Montgomery G.I. Bill, and Vocational Rehabilitation and Employment programs and adjust the reduction targets to reasonably achievable levels, if necessary.
Closure Date:
3 We recommended the Under Secretary for Benefits implement revised testing plans for the Post-9/11 G.I. Bill and its other reported Education programs that ensure valid and auditable estimates of improper payments.
Closure Date:
4 We recommended that the Acting Assistant Secretary for Management improve the risk assessment guidance and instructions to include an assessment of risk associated with contracting activities.
Closure Date:
5 We recommended that the Acting Assistant Secretary for Management perform risk assessments for programs with a high concentration of vendor payments using revised procedures that include contracting risk.
Closure Date:
6 We recommended that the Under Secretary for Benefits ensure thorough testing of sample items used to estimate improper payments for the Compensation program.
Closure Date:
7 We recommended that the Under Secretary for Benefits consult with the Office of Management and Budget regarding the potential designation of the Compensation program as a high-priority program.
Closure Date:
8 We recommended that the Under Secretary for Benefits use the annual Department of Defense drill pay matching file to identify improper drill pay-related payments in its Compensation and Pension program samples to ensure accurate and auditable reporting.
Closure Date:
9 We recommended that the Interim Under Secretary for Health improve test procedures for the Non-VA Medical Care and Purchased Long Term Services and Support programs by verifying the existence of valid contracts that support payments for these programs.
Closure Date:
| ||||
| 15-00124-227 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Nebraska-Western Iowa Health Care System, Omaha, Nebraska | Comprehensive Healthcare Inspection Program | ||
1 We recommended that fire drills are performed every 12 months
at the O’Neill VA Clinic.
2 We recommended that Clinic Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
3 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.
4 We recommended that the Facility Director develops policies and
procedures that facilitate human immunodeficiency virus testing as part of routine
medical care for patients.
5 We recommended that clinicians provide human
immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
| ||||
| 15-00110-228 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Palo Alto Health Care System, Palo Alto, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that employees at the Fremont CBOC receive the required training on hazardous materials.
Closure Date:
2 We recommended that staff protect patient-identifiable information on laboratory specimens during transport from the Fremont CBOC to the parent facility.
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 Registered Nurse Care Managers receive motivational interviewing and health coaching training 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 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 consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
| ||||
| 15-00129-339 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA Roseburg Healthcare System, Roseburg, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that all safety inspections are performed on the medical equipment at the Brookings CBOC in accordance with Joint Commission standards.
Closure Date:
2 We recommended that managers monitor hand hygiene compliance at the Brookings CBOC and report compliance levels to the Infection Control Committee.
Closure Date:
3 We recommended that the information technology staff maintain the information technology server closet at the Brookings CBOC according to information technology safety and security standards.
Closure Date:
4 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
5 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.
Closure Date:
6 We recommended that clinic staff consistently document the offer of further treatment to patients diagnosed with alcohol dependence.
Closure Date:
7 We recommended that Clinic Registered Nurse Care Managers and clinical associates receive health coach training as required.
Closure Date:
8 We recommended that clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
| ||||
| 14-04493-198 | Review of Alleged Mismanagement of Radiologists Interpretations at Central Arkansas Veterans Healthcare System | Audit | ||
1 We recommended the Interim Veterans Integrated Service Network 16 Director review TalkStation data showing the time interpretations started and ended to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
Closure Date:
2 We recommended the Interim Veterans Integrated Service Network 16 Director require the Central Arkansas Veterans Healthcare System to establish policy on an official tour of duty for weekends to ensure radiologists perform Teleradiology Reading Center interpretations during their non-duty hours.
Closure Date:
3 We recommended the Interim Veterans Integrated Service Network 16 Director annually review the Teleradiology Reading Center agreement and certify that services are still needed, qualified individuals in the specialty are not available locally, and other business options have been considered for obtaining services.
Closure Date:
| ||||
| 15-00032-226 | Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California | Hotline Healthcare Inspection | ||
1 We recommended that the facility establish a committee to provide oversight of the safe patient handling program.
Closure Date:
2 We recommended that facility managers ensure employees receive training on chemical labeling/safety data sheets.
Closure Date:
3 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
Closure Date:
4 We recommended that facility managers ensure personal protective equipment gowns, eye protection, and masks are available in various sizes in patient care areas and monitor compliance.
Closure Date:
5 We recommended that facility managers ensure all designated critical care and community living center employees receive annual bloodborne pathogens training and monitor compliance.
Closure Date:
6 We recommended that the facility conduct initial patient safety screenings prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
7 We recommended that Level 2 magnetic resonance imaging personnel conducting secondary patient safety screenings sign the forms prior to magnetic resonance imaging and that facility managers monitor compliance.
Closure Date:
8 We recommended that radiologists and/or Level 2 magnetic resonance imaging personnel document resolution in patients' electronic health records of all identified magnetic resonance imaging contraindications prior to the scan and that facility managers monitor compliance.
Closure Date:
9 We recommended that the facility ensure all designated Level 1 ancillary staff receive annual level-specific magnetic resonance imaging safety training and that facility managers monitor compliance.
Closure Date:
10 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
Closure Date:
11 We recommended that facility managers post stroke guidelines on the critical care and medical/surgical units.
Closure Date:
12 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
Closure Date:
13 We recommended that the facility report to the Medical Executive Board the percent of eligible patients given tissue plasminogen activator, the percent of patients with stroke symptoms who had the stroke scale completed, and the percent of patients screened for difficulty swallowing before oral intake.
Closure Date:
14 We recommended that clinicians obtain cardiac markers, prothrombin time/international normalized ratio, and partial thromboplastin time while assessing patients presenting with stroke symptoms and that facility managers monitor compliance.
Closure Date:
| ||||
| 14-02916-336 | Review of VA's Patient-Centered Community Care (PC3) Contracts' Estimated Costs Savings | Audit | ||
1 We recommended the Interim Under Secretary for Health assign an accountable senior executive to prepare and document revised Patient-Centered Community Care price analyses and determine if VA will realize any cost savings during the future option years of the contracts.
Closure Date:
2 We recommended the Interim Under Secretary for Health develop an action plan to address low PC3 contract utilization rates.
Closure Date:
3 We recommended the Executive Director, Office of Acquisition, Logistics, and Construction ensure all required contract documents are maintained in the official Patient-Centered Community Care contract files in accordance with Federal Acquisition Regulation and hold the contracting officer accountable for ensuring complete and accurate information is maintained in the Electronic Contract Management System.
Closure Date:
| ||||
| 15-00114-212 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
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 clinicians provide human immunodeficiency virus testing as part of routine medical care for patients and that compliance is monitored.
| ||||
15039