Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 15-00123-211 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of VA St. Louis Health Care System, St. Louis, Missouri | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the information technology server closet at the Primary Care Team 2 Annex 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 Registered Nurse Care Managers receive motivational interviewing training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
4 We recommended that Clinic Registered Nurse Care Managers, providers, and clinical associates receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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| 15-00074-207 | Combined Assessment Program Review of the Veterans Health Care System of the Ozarks, Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain non-allowed information.
2 We recommended that the Intensive Care Unit Committee document the review of each code episode and that code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
3 We recommended that the Chief of Staff attend Surgical Work Group meetings and that the Surgical Work Group document its review of National Surgical Office reports.
4 We recommended that the Facility Director approve and sign written requests for extensions for final peer reviews.
5 We recommended that Environment of Care Committee meeting minutes consistently include discussion regarding community based outpatient clinic rounds deficiencies.
6 We recommended that the Infection Control Committee meeting minutes consistently include implementation of actions to address all high-risk areas, follow-up on implemented actions, and analysis of surveillance activities and data.
7 We recommended that facility managers ensure patient care areas are in good repair and monitor compliance.
8 We recommended that the facility correctly tag critical medical equipment on the intensive care unit and inspect and maintain it as recommended by the manufacturer and that facility managers monitor compliance.
9 We recommended that the facility remove inoperable medical equipment from use.
10 We recommended that the facility annually review the look-alike and sound-alike medication list.
11 We recommended that the facility conduct a contrast reaction emergency drill in magnetic resonance imaging and that facility managers monitor compliance.
12 We recommended that 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.
13 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
14 We recommended that facility managers post stroke guidelines on all required units.
15 We recommended that clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
16 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
17 We recommended that the facility ensure that employees who are involved in assessing and treating stroke patients receive the training required by the facility and that facility managers monitor compliance.
18 We recommended that the facility revise the emergency airway management policy to include a plan for managing a difficult airway.
19 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.
20 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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| 14-00378-208 | Combined Assessment Program Summary Report - Evaluation of Quality Management in Veterans Health Administration Facilities Fiscal Year 2014 | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers complete improvement actions related to peer review and report the completion to the Peer Review Committee and that the Peer Review Committee submits quarterly reports to the Medical Executive Committee.
Closure Date:
2 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that the Medical Executive Committee documents approval when telemedicine services are received or provided.
Closure Date:
3 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinical managers reassess observation criteria and/or utilization when the conversion rate from observation to admission was greater than the allowed percent.
Closure Date:
4 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that clinicians complete reviews of inpatients’ continuing stays.
Closure Date:
5 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirement for an interdisciplinary committee to review individual resuscitation episodes and for facilities to collect resuscitation data.
Closure Date:
6 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, ensure that transfusion committees meet at least quarterly; include clinical representation from Medicine, Surgical, and Anesthesia Services; and review all required elements.
Closure Date:
7 We recommended that the Interim Under Secretary for Health, in conjunction with Veterans Integrated Service Networks and facility senior managers, re-emphasize the requirements for Surgical Work Groups to meet monthly, include the Chief of Staff as a member, monitor surgical performance improvement activities, and review National Surgery Office reports.
Closure Date:
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| 15-00030-202 | Combined Assessment Program Review of the Martinsburg VA Medical Center, Martinsburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Medical Executive Committee review privilege forms annually and document the review.
Closure Date:
2 We recommended that facility managers ensure that licensed independent practitioners who perform emergency airway management have the appropriate skills and training.
Closure Date:
3 We recommended that the facility ensure that licensed independent practitioners’ folders do not contain licensure verification information.
Closure Date:
4 We recommended that Code Blue Committee code reviews include screening for clinical issues prior to the code that may have contributed to the occurrence of the code.
Closure Date:
5 We recommended that facility managers ensure patient care areas are clean and monitor compliance.
Closure Date:
6 We recommended that the facility secure sterile supply cabinets when not in use and that facility managers monitor compliance.
Closure Date:
7 We recommended that the facility promptly remove outdated commercial supplies from examination rooms and that facility managers monitor compliance.
Closure Date:
8 We recommended that facility managers ensure employees lock computers and secure sensitive patient information when they leave the area and monitor compliance.
Closure Date:
9 We recommended that the facility revise the policy for safe use of automated dispensing machines to include employee training and minimum competency requirements for users 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 clinicians screen patients for difficulty swallowing prior to oral intake and that facility managers monitor compliance.
Closure Date:
12 We recommended that the facility collect and report to the Veterans Health Administration 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:
13 We recommended that facility managers ensure that intensive care unit, Emergency Department, and medical/surgical unit (4A) employees have 12-lead electrocardiogram competency assessment and validation included in their competency checklists and completed and documented.
Closure Date:
14 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is included in competency checklists and completed and documented for employees on the intensive care unit.
Closure Date:
15 We recommended that the facility ensure assessment of clinicians for emergency airway management competency prior to granting of privileges and that facility managers monitor competency.
Closure Date:
16 We recommended that the facility ensure clinician reassessment for continued emergency airway management competency is completed at the time of renewal of privileges and includes all required elements and that facility managers monitor compliance.
Closure Date:
17 We recommended that the facility correct the identified deficiencies in the domiciliary and that documentation reflect correction.
Closure Date:
18 We recommended that domiciliary managers ensure that written agreements are in place acknowledging resident responsibility for medication security.
Closure Date:
19 We recommended that domiciliary program managers ensure residents secure medications in their rooms and monitor compliance.
Closure Date:
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| 15-00121-201 | Review of Community Based Outpatient Clinics and Other Outpatient Clinics of Veterans Health Care System of the Ozarks, Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that a functional panic alarm system is installed at the Jay CBOC.
Closure Date:
2 We recommended that clinic staff document a plan to monitor the alcohol use of patients who decline referral to specialty care.
Closure Date:
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.
Closure Date:
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.
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:
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| 14-03651-203 | Review of Alleged Data Manipulation and Mismanagement at VA Regional Office Philadelphia, PA | Audit | ||
1 We recommended the Under Secretary for Benefits convene an Administrative Investigation Board to determine if VA Regional Office management intentionally misapplied the guidance as a means to remove aging claims from its inventory.
Closure Date:
2 We recommended the Under Secretary for Benefits review leadership performance and restore accountability for completing work requirements in accordance with Veterans Benefits Administration policy.
Closure Date:
3 We recommended the Philadelphia VA Regional Office Director implement a plan to ensure staff follow the standardized checklist when conducting and entering internal quality reviews results.
Closure Date:
4 We recommended the Philadelphia VA Regional Office Director take appropriate administrative action to hold staff accountable for altering quality review results.
Closure Date:
5 We recommended the Philadelphia VA Regional Office Director conduct a review of the 52 altered quality reviews to determine if the altered results affected veterans' benefits or an individual's performance and take corrective actions as required.
Closure Date:
6 We recommended the Philadelphia VA Regional Office implement a plan to ensure and effectively monitor staff enter appealed claims in Veterans Appeals Control and Locator System within 7 days to ensure accurate and timely reporting to stakeholders.
Closure Date:
7 We recommended the Philadelphia VA Regional Office Director implement a plan to ensure efficient operations when processing appealed claims, to include determining if additional staffing is required to process approximately 700 appealed claims from another VA Regional Office.
Closure Date:
8 We recommended the Under Secretary for Benefits implement a contingency plan to address backlogged inquiries received through the Inquiry Routing and Information System to ensure timely responses are provided to veterans and their families.
Closure Date:
9 We recommended the Under Secretary for Benefits clarify timeliness goals for responding to inquiries received through the Inquiry Routing and Information System.
Closure Date:
10 We recommended the Under Secretary for Benefits modify performance measures to include the number of pending electronic inquiries awaiting responses from VA Regional Office staff.
Closure Date:
11 We recommended the Philadelphia VA Regional Office Director ensure supervisory staff receive refresher training on records management disposition.
Closure Date:
12 We recommended the Philadelphia VA Regional Office Director implement a plan that includes periodic reviews of records maintained by supervisory staff to ensure records are disposed of according to the records control schedule.
Closure Date:
13 We recommended the Under Secretary for Benefits establish policies and procedures to standardize procedures for merging duplicate records that includes timeliness goals and oversight responsibility.
Closure Date:
14 We recommended the Philadelphia VA Regional Office Director take immediate action to merge the 248 duplicate records identified during our review and take timely action to terminate any improper payments associated with those records.
Closure Date:
15 We recommended the Under Secretary for Benefits develop and implement a plan to routinely provide VA Regional Office staff a listing of duplicate records and payment information so timely, corrective actions can be taken to merge the records and terminate improper payments.
Closure Date:
16 We recommended the Under Secretary for Benefits clarify policies and procedures related to recouping improper payments resulting from duplicate records.
Closure Date:
17 We recommended the Under Secretary for Benefits revise policies and procedures to emphasize VA Regional Offices must minimize the number of date stamps issued, limit use of date stamps to authorized staff, and control date stamp keys as measures to prevent and deter potential fraudulent activity.
Closure Date:
18 We recommended the Under Secretary for Benefits direct the Philadelphia VA Regional Office Director ensure staff process all mail concerning beneficiaries in the mailroom within 6 hours of receipt.
Closure Date:
19 We recommended the Under Secretary for Benefits initiate independent, unannounced reviews of the Philadelphia VA Regional Office to ensure staff process mail within 6 hours of receiving the mail.
Closure Date:
20 We recommended the Under Secretary for Benefits develop and implement a plan to ensure VA Regional Office staff prioritize scanning documents to the Veterans Benefits Administration's electronic repository to ensure the documents are timely associated with electronic claims folders.
Closure Date:
21 We recommended the Under Secretary for Benefits develop and implement a timeliness goal for scanning and uploading documents to the Veterans Benefits Administration's electronic repository.
Closure Date:
22 We recommended the Under Secretary for Benefits examine the effectiveness of Pension and Fiduciary Services' strategies for following up and closing out recommendations for improvement resulting from site visits.
Closure Date:
23 We recommended the Under Secretary for Benefits develop and implement a plan to ensure Philadelphia VA Regional Office staff take action to process its backlog of returned mail.
Closure Date:
24 We recommended the Under Secretary for Benefits develop and implement a timeliness goal for VARO Offices to process returned mail.
Closure Date:
25 We recommended the Under Secretary for Benefits implement procedures to ensure the improvement actions identified and recommended by VBA's internal review teams are appropriately addressed.
Closure Date:
26 We recommended the Under Secretary for Benefits develop and implement standardized procedures that includes an audit trail for the destruction of military file mail.
Closure Date:
27 We recommended the Under Secretary for Benefits develop and implement a plan to conduct routine accuracy reviews of mail categorized as military file mail prior to destruction.
Closure Date:
28 We recommended the Under Secretary for Benefits conduct an independent review of all military file mail pending destruction at the Philadelphia VA Regional Office.
Closure Date:
29 We recommended the Philadelphia VA Regional Office Director ensure claims processing staff at the Philadelphia Pension Management Center receive refresher training on identifying and processing military file mail.
Closure Date:
30 We recommended the Under Secretary for Benefits develop and implement a plan to ensure Philadelphia VA Regional Office staff associate the remaining backlog of drop mail with veterans' claims.
Closure Date:
31 We recommended the Under Secretary for Benefits develop and implement a plan that includes a timeliness goal to ensure mail is associated with electronic or paper claims folders prior to claims processing actions.
Closure Date:
32 We recommended the Philadelphia VA Regional Office Director develop a plan that includes routine supervisory reviews of all space accessible by VA Regional Office staff as a measure to prevent improper storage of documents containing personally identifiable data.
Closure Date:
33 We recommended the Under Secretary for Benefits take immediate action to ensure Veterans Benefits Administration workspace complies with VA Occupational Safety and Health requirements contained in Federal laws, regulations, and executive orders.
Closure Date:
34 We recommended the Philadelphia VA Regional Office Director ensure veterans' records and VA equipment are adequately safeguarded.
Closure Date:
35 We recommend the Under Secretary for Benefits conduct an independent review of production standards for the Pension Call Center staff to determine if the timeliness standard is
reasonable and obtainable without comprising the quality of customer service to callers.
Closure Date:
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| 15-01332-121 | Review of Alleged Data Manipulation at VA Regional Office, Boston, Massachusetts | Audit | ||
1 We recommended the Under Secretary for Benefits implement a plan to ensure only specifically authorized staff at the Boston VA Regional Office use date stamping equipment.
Closure Date:
2 We recommended the Under Secretary for Benefits implement a plan to ensure claims processing staff at the Boston VA Regional Office receive training on securing date stamping equipment.
Closure Date:
3 We recommended the Under Secretary for Benefits implement a plan to ensure staff at the Boston VA Regional Office secure the keys needed to open and operate date stamping equipment.
Closure Date:
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| 14-03824-155 | Healthcare Inspection – Lapses in Access and Quality of Care, VA Maryland Health Care System, Baltimore, Maryland | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that patient aligned care team provider staffing is adequate to provide patients with timely access to care.
Closure Date:
2 We recommended that the System Director ensure that a contingency plan for patient aligned care team provider shortages is developed.
Closure Date:
3 We recommended that the System Director ensure that patient aligned care team cancellations and other data are monitored to determine when there is a need to activate a contingency plan.
Closure Date:
4 We recommended that the System Director ensure that staff comply with local and national policies on contacting patients when scheduling mental health services.
Closure Date:
5 We recommended that the System Director ensure that policy requirements for discontinuation of mental health consultation are clear and that staff comply with those requirements.
Closure Date:
6 We recommended that the System Director ensure that the Access Action Plan for Orthopedic Surgery Services is carried out in an effort to improve access to orthopedic surgical services.
Closure Date:
7 We recommended that the System Director ensure that providers comply with their responsibilities of electronic health record documentation of the community care of co-managed patients.
Closure Date:
8 We recommended that the System Director ensure compliance with local policy requiring that community health care records be scanned into the electronic health records of co-managed patients.
Closure Date:
9 We recommended that the System Director ensure that the local outpatient tube-feeding policy and practice comply with Veterans Health Administration requirements.
Closure Date:
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| 13-01730-159 | Administrative Investigation, Improper Access to the VA Network by VA Contractors from Foreign Countries, Office of Information and Technology, Austin, TX | Administrative Investigation | ||
1 We recommend that the VA Chief of Staff (COS) confer with the Offices of Human Resources (OHR), General Counsel (OGC), and Accountability Review (OAR) to determine the appropriate administrative action to take, if any, against the OIT employees involved in this particular matter.
Closure Date:
2 We recommend that the COS confer with OGC and the Executive Director of the Office of Acquisition Operations (OAO) to determine the appropriate action to take against Systems Made Simple, Inc., for contractor employees failing to adhere to VA information security policies and contract security requirements.
Closure Date:
3 We recommend that the COS ensure that VA's information security policies are thoroughly reviewed and rewritten to address any weaknesses.
Closure Date:
4 We recommend that the COS ensure that VA's information security training is thoroughly reviewed and rewritten to address any weaknesses.
Closure Date:
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| 15-00073-200 | Combined Assessment Program Review of the Dayton VA Medical Center, Dayton, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Special Care Unit Committee review each code episode.
2 We recommended that the Surgical Quality Council meet monthly and document its review of National Surgical Office reports.
3 We recommended that the Surgical Quality Council review all surgical deaths with identified problems or opportunities for improvement.
4 We recommended that the facility store clean and dirty items separately and that facility managers monitor compliance.
5 We recommended that the facility use special medication labeling and unique storage practices for look-alike and sound-alike medications and that facility managers monitor compliance.
6 We recommended that facility managers ensure monthly medication storage area inspections are completed and monitor compliance.
7 We recommended that the facility consistently implement corrective actions for issues identified during monthly medication storage area inspections and that facility managers monitor the changes until issues are fully resolved.
8 We recommended that the facility revise the policy for safe use of automated dispensing machines to include oversight of overrides and employee training and minimum competency requirements for users and that facility managers monitor compliance.
9 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.
10 We recommended that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that facility managers monitor compliance.
11 We recommended that clinicians provide printed stroke education to patients upon discharge and that facility managers monitor compliance.
12 We recommended that facility managers revise local policies to require that radiology interpretation and computerized tomography coverage be available on call within 30 minutes.
13 We recommended that facility managers ensure post-anesthesia care competency assessment and validation is completed for employees on the intensive care unit.
14 We recommended that facility managers initiate actions to minimize a repeat occurrence in which a non-privileged clinician performs an intubation, and if this does occur, facility managers initiate a root cause analysis.
15 We recommended that facility managers ensure that monthly inspections of the Mental Health Residential Rehabilitation Treatment Programs include all required elements.
16 We recommended that Mental Health Residential Rehabilitation Treatment Program managers ensure that the programs have written agreements in place acknowledging resident responsibility for medication security.
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