Recommendations
2108
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-01297-368 | Community Based Outpatient Clinics Summary Report ─ Evaluation of Medication Oversight and Education at Community Based Outpatient Clinics and Other Outpatient Clinics | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians perform and document medication reconciliation at each outpatient episode of care when a new medication is prescribed.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently provide and document patient education for new outpatient medications.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians consistently assess and document outpatients' understanding of medication education.
Closure Date:
| ||||
| 15-02456-396 | Healthcare Inspection – Care of an Urgent Care Clinic Patient, Tomah VA Medical Center, Tomah, Wisconsin | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health review current acute stroke treatment policies, and assess the use of telehealth evaluation and more aggressive local treatment in patients presenting to rural and/or low complexity VHA facilities with signs and symptoms of an acute stroke.
Closure Date:
2 We recommended that the Under Secretary for Health review processes to improve the ability to identify unauthorized access to VA medical records.
Closure Date:
3 We recommended that the Under Secretary for Health evaluate the complex rules related to reimbursement for a veteran’s emergency care at non-VA facilities, and determine if changes in policy or law would make it more likely that veterans would make decisions on where to seek emergency care based upon medical circumstances, rather than fear of adverse financial impact.
Closure Date:
4 We recommended that the Facility Director ensure that patients and their families are educated about the services the UCC is equipped to provide.
Closure Date:
5 We recommended that the Facility Director ensure that employees who are involved in assessing and treating stroke patients receive the web-based acute ischemic stroke training required by the facility and that facility managers monitor compliance.
Closure Date:
6 We recommended that the Facility Director ensure that transfer agreements are established as required.
Closure Date:
7 We recommended that the Facility Director review and evaluate computerized tomography scanner routine maintenance schedules to determine if routine maintenance can be conducted during periods of traditionally low utilization.
Closure Date:
8 We recommended that the Facility Director ensure Urgent Care Clinic processes are strengthened to reduce door-to-triage timeliness.
Closure Date:
9 We recommended that the Facility Director ensure that appropriate staff receive Emergency Department Integration Software training.
Closure Date:
| ||||
| 14-05158-377 | Healthcare Inspection – Mismanagement of Mental Health Consults and Other Access to Care Concerns, VA Maine Healthcare System, Augusta, ME | Hotline Healthcare Inspection | ||
1 We recommended the Facility Director remove the language in the Computerized Patient Record System outpatient psychological testing consult that may be interpreted as instructing providers not to enter a consult.
Closure Date:
2 We recommended the Facility Director reevaluate and make the appropriate changes to the methods for referring patients for mental health care, including the extent to which the consult package is being used appropriately.
Closure Date:
3 We recommended the Facility Director ensure that mental health consults are reviewed and closed in accordance with Veterans Health Administration policy.
Closure Date:
4 We recommended the Facility Director ensure that Veterans Health Administration appointment scheduling guidance is followed and that schedulers utilize the electronic waiting list and give priority to service connected veterans, as appropriate.
Closure Date:
5 We recommended the Facility Director review all existing mental health wait lists to identify patients who may be at risk because of a delay in the delivery of mental health care and provide the appropriate care.
Closure Date:
6 We recommended the Facility Director expand access to mental health services, particularly required evidence-based psychotherapy and intensive case management services.
Closure Date:
7 We recommended the Facility Director ensure that mental health staff is available in the Emergency Department as required by Veteran Health Administration and local policy to avoid potential delays in admission to the inpatient psychiatry unit.
Closure Date:
8 We recommended the Facility Director review guidance provided to staff about meeting performance measures and confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any.
Closure Date:
| ||||
| 14-00730-206 | Review of Alleged Improper Advances of VHA Appropriated Funds to the U.S. Government Printing Office | Audit | ||
1 We recommended Deputy Assistant Secretary for Acquisition and Logistics take steps to consult with the Office of General Counsel to remedy the inappropriate expenditure of approximately $2.3 million of expired funds, determine whether VA should
de-obligate any outstanding balances, and evaluate the need to return Supply Fund service fees of approximately $5.6 million.
Closure Date:
2 We recommended Deputy Assistant Secretary for Acquisition and Logistics implement a corrective action plan to ensure that fiscal controls are enforced to avoid future misuse of appropriated funds, including inappropriate use of the VA Supply Fund, and the parking of funds.
Closure Date:
3 We recommended the Deputy Assistant Secretary for Finance review the fiscal controls in the Financial Management System to ensure data integrity and an audit trail that reflects the occurrence and source of any accounting record changes.
Closure Date:
4 We recommended the Deputy Under Secretary for Health for Operations and Management confer with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action to take, if any, against
Chief Business Office officials for directing the misuse of approximately $43.1 million of fiscal year 2011 appropriated funds.
Closure Date:
5 We recommended the Deputy Assistant Secretary for Acquisition, Logistics, and Construction confer with the Office of Human Resources and the VA Office of General Counsel to determine the appropriate administrative action to take, if any, against Supply Fund management for circumventing controls over the management of funds.
Closure Date:
| ||||
| 14-04573-378 | Healthcare Inspection – Quality of Care and Access to Care Concerns, Jack C. Montgomery VA Medical Center, Muskogee, OK | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director evaluate the care of the cases discussed in this report with Regional Counsel for possible disclosure(s) to the patient(s) and/or surviving family members.
2 We recommended that the Veterans Integrated Service Network Director require the Facility Director to conduct peer reviews of the cases identified in this report and take appropriate action to evaluate clinical competence of the providers involved in these cases based on the results of those reviews and this report.
3 We recommended that the Veterans Integrated Service Network Director send a team to evaluate the facility’s Dental Service and oversee the implementation of any recommendations for improvement in scheduling and the general provision of dental care at the facility made by that team.
4 We recommended that the Veterans Integrated Service Network Director ensure that the Facility Director provide appropriate and timely neurosurgical consultation services to patients receiving care at the facility consistent with Veterans Health Administration Directive 2008-056, VHA Consult Policy, September 16, 2008.
5 We recommended that the Facility Director ensure that all documents that patients and non-VA providers receive regarding maternity/obstetric care and services are reviewed and revised to eliminate ambiguous language.
6 We recommended that the Facility Director ensure that providers document all clinically pertinent telephone conversations concerning patient care.
7 We recommended that Veterans Integrated Service Network and the Facility Director ensure adequate parking space requirements to strengthen a safe work environment, patient satisfaction, and provide optimal safety to patients, visitors, and staff.
8 We recommended that the Veterans Integrated Service Network and the Facility Director ensure that Ernest Childers VA Outpatient Clinic access and parking is adequate and safe for patients, visitors, and employees.
| ||||
| 15-00359-374 | Combined Assessment Program Summary Report - Evaluation of Medication Oversight and Education in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians adjust fluoroquinolone doses and/or frequencies consistent with manufacturers' recommendations when patients' estimated glomerular filtration rate values are below targeted thresholds.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that clinicians providing medication education document the accommodations made to address patients¿ identified learning barriers.
Closure Date:
| ||||
| 15-02354-220 | Review of Second Instance of Employee Data Manipulation at the Houston VA Regional Office | Audit | ||
1 We recommended the Houston VA Regional Office Director take immediate action to fully review and correct, as appropriate, all actions the employee took to clear or cancel controls for claims.
Closure Date:
2 We recommended the Houston VA Regional Office Director confer with Regional Counsel to determine the appropriate administrative action to take, if any, against this employee.
Closure Date:
3 We recommended the Houston VA Regional Office Director implement a plan to routinely monitor system controls for pending claims, to prevent further manipulation attempts and ensure staff do not prematurely change or remove controls.
Closure Date:
4 We recommended the Houston VA Regional Office Director submit the 13 remaining and previously unavailable claims the employee cancelled in FY 2013 to OIG for review.
Closure Date:
| ||||
| 15-00425-380 | Healthcare Inspection – Medication Management Concerns, South Texas Veterans Health Care System, San Antonio, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that processes be developed to improve storage conditions of compounded sterile products on applicable patient units in an effort to reduce unnecessary waste.
Closure Date:
| ||||
| 14-02195-381 | Healthcare Inspection – Alleged Magnetic Resonance Imaging Order Deletion and Record Destruction, VA Greater Los Angeles Healthcare System, Los Angeles, CA | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that Radiology Department managers confirm that ordered magnetic resonance imaging exams are scheduled and completed within the Veterans Health Administration required timeframe.
Closure Date:
2 We recommended that the Facility Director require Radiology Department managers to review pending lists of magnetic resonance imaging exams at designated intervals to ensure timely scheduling of these exams and that compliance be monitored.
Closure Date:
3 We recommended that the Facility Director ensure Radiology Department managers develop and implement a consistent procedure for canceling magnetic resonance imaging orders.
Closure Date:
4 We recommended that the Facility Director ensure that responsible providers are notified of canceled magnetic resonance imaging orders.
Closure Date:
5 We recommended that the Facility Director ensure that radiology clerical staff accurately annotate reasons for canceling magnetic resonance imaging orders and appointments in the electronic health record.
Closure Date:
| ||||
| 15-00143-372 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of North Florida/South Georgia Veterans Health System, Gainesville, Florida | 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.
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 managers ensure that patients with excessive persistent alcohol use receive brief treatment or are evaluated by a specialty provider within 2 weeks of the screening.
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 Registered Nurse Care Managers, providers, and clinical associates in the outpatient clinics receive health coach training within 12 months of appointment to Patient Aligned Care Teams.
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 clinicians consistently document informed consent for human immunodeficiency virus testing and that compliance is monitored.
Closure Date:
8 We recommended that clinicians consistently notify patients of their laboratory results within 14 days, per local and VHA policy.
Closure Date:
| ||||
15211