Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 14-00928-291 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Bath VA Medical Center, Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/Primary Care Clinic staff consistently complete diagnostic assessments for patients with a positive alcohol screen.
Closure Date:
2 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers complete required training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
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| 14-02075-292 | Combined Assessment Program Review of the Bath VA Medical Center, Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are completed and reported to the Peer Review Committee.
Closure Date:
2 We recommended that the Medical Executive Committee discuss and document its approval of the use of another facility's providers for teledermatology services.
Closure Date:
3 We recommended that processes be strengthened to ensure that the Morbidity and Mortality Committee review process includes the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria.
Closure Date:
4 We recommended that processes be strengthened to ensure that clinicians complete and document National Institutes of Health stroke scales for each stroke patient and that compliance be monitored.
Closure Date:
5 We recommended that the facility consistently collect and report to VHA 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:
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| 13-03065-304 | Administrative Investigation, Conduct Prejudicial to the Government and Interference of a VA Official for the Financial Benefit of a Contractor, Veterans Health Administration, Procurement & Logistics Office, Washington, DC | Administrative Investigation | ||
1 We recommend that the PDUSH confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take, if any, against Ms. Taylor.
2 We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against Mr. Ryan.
3 We recommend that the PDUSH confer with OHR and OGC to determine the appropriate administrative action to take, if any, against the VHA Lead Contracting Specialist.
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| 14-00929-287 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Tennessee Valley Healthcare System, Nashville, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the CBOC is Americans with Disabilities Act accessible at the Maury County CBOC.
Closure Date:
2 We recommended that managers ensure staff can access the electronic version of hazardous materials information at the Maury County CBOC.
Closure Date:
3 We recommended that processes are improved to ensure the tracking of hazardous materials at the Maury County CBOC.
Closure Date:
4 We recommended that the effectiveness of the panic alarm system is evaluated at the Maury County CBOC.
Closure Date:
5 We recommended that signage is installed at the Maury County CBOC to clearly identify the location of fire all extinguishers.
Closure Date:
6 We recommended that medications are secured and accessible only by individuals who either dispense or administer medications at the Maury County CBOC, and that compliance is monitored.
Closure Date:
7 We recommended that managers ensure that personally identifiable information is protected by securing laboratory specimens during transport from the Maury County CBOC to the parent facility.
Closure Date:
8 We recommended that that that the information technology server closet at the Maury County CBOC is maintained according to information technology safety and security standards.
Closure Date:
9 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:
10 We recommended that CBOC and Primary Care Clinic Registered Nurse Care Managers receive motivational interviewing training and health coaching training within 12 months of appointment to Patient Aligned Care Teams.
Closure Date:
11 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
Closure Date:
12 We recommended that staff consistently provide patients with medication counseling and written medication information that includes the fluoroquinolone.
Closure Date:
13 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
Closure Date:
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| 14-01502-259 | Inspection of VA Regional Office Seattle, Washington | Review | ||
1 We recommend the Seattle VA Regional Office Director implement a plan to ensure timely and appropriate action on reminder notifications for medical reexaminations.
2 We recommend the Seattle VA Regional Office Director implement a plan to review for accuracy the 576 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate actions.
3 We recommend the Seattle VA Regional Office Director develop and implement a plan to ensure staff receive refresher training on processing claims related to special monthly compensation and ancillary benefits and implement a plan to monitor the effectiveness of that training.
4 We recommend the Seattle VA Regional Office Director amend its secondary-review policy by reducing the special monthly compensation threshold for requiring second-signature reviews as a means of ensuring accuracy in processing these complex claims.
5 We recommend the Seattle Regional Office Director implement a plan to ensure claims processing staff prioritize actions related to benefits reductions to minimize improper payments to veterans.
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| 14-02198-284 | Community Based Outpatient Clinic Summary Report — Evaluation of CBOC Cervical Cancer Screening and Results Reporting | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying ordering providers of abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
Closure Date:
2 We recommended that the Interim Under Secretary for Health ensure that a consistent process is established for notifying women veterans of normal and abnormal cervical cancer screening results within the required timeframe and that notification is documented in the electronic health record.
Closure Date:
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| 14-02357-270 | Inspection of VA Regional Office Chicago, Illinois | Review | ||
1 We recommended the Chicago VA Regional Office Director conduct a review of the 581 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommended the Chicago VA Regional Office Director provide oversight to ensure staff follow Veterans Benefits Administration guidance for establishing suspense diaries and processing reminder notifications.
Closure Date:
3 We recommended the Chicago VA Regional Office Director ensure staff receive refresher training on the proper processing of special monthly compensation and ancillary benefits and implement a plan to ensure the effectiveness of the training.
Closure Date:
4 We recommended the Chicago VA Regional Office Director develop and implement a plan to ensure completion of all Systematic Analyses of Operations.
Closure Date:
5 We recommended the Chicago VA Regional Office Director amend, implement, and monitor the local Workload Management Plan to ensure staff take timely action on claims requiring rating decisions for reduction of benefits.
Closure Date:
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| 14-03736-273 | Review of Alleged Data Manipulation at the Los Angeles VA Regional Office | Audit | ||
1 We recommended the Los Angeles VA Regional Office Director take action to review and correct all entries the employee made in the electronic system on the 14 claims we identified.
Closure Date:
2 We recommended the Los Angeles VA Regional Office Director ensure monitoring of all employees’ work for the future to ensure that all work is performed in accordance with VBA policy.
Closure Date:
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| 14-00926-281 | Community Based Outpatient Clinic and Primary Care Clinic Reviews at Alexandria VA Health Care System, Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 We recommended that CBOC/Primary Care Clinic staff provide education and counseling for patients with positive alcohol screens and drinking alcohol above National Institute on Alcohol Abuse and Alcoholism limits.
2 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.
3 We recommended that CBOC/Primary Care Clinic Registered Nurse Care Managers receive health coaching training within 12 months of appointment to Patient Aligned Care Teams.
4 We recommended that staff document that medication reconciliation was completed at each episode of care where the newly prescribed fluoroquinolone was administered, prescribed, or modified.
5 We recommended that staff document the evaluation of patient’s level of understanding for the medication education.
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| 14-02072-283 | Combined Assessment Program Review of the VA Southern Oregon Rehabilitation Center and Clinics, White City, Oregon | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the facility implement a quality control policy for scanning that includes all required elements.
Closure Date:
2 We recommended that processes be strengthened to ensure that infection prevention educational materials are available for eye clinic patients, visitors, and family members.
Closure Date:
3 We recommended that processes be strengthened to ensure that dirty items in the eye clinic are not stored in patient care areas and that compliance be monitored.
Closure Date:
4 We recommended that processes be strengthened to ensure that employees reprocess ophthalmology pachymetry probes in accordance with manufacturer's instructions and that compliance be monitored.
Closure Date:
5 We recommended that facility policy be amended to include that Controlled Substances Coordinators must be free from conflicts of interest, that controlled substances inspectors must be appointed in writing, and that annual updates for controlled substances inspectors include problematic issues identified through external survey findings and other quality control measures.
Closure Date:
6 We recommended that the facility develop instructions for inspections of automated dispensing machines.
Closure Date:
7 We recommended that processes be strengthened to ensure that the medical information from non-VA hospitalizations is consistently scanned into the electronic health records and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that licensed independent practitioners are notified of critical laboratory test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
Closure Date:
9 We recommended that processes be strengthened to ensure that all patients are notified of normal test results/values within the expected timeframe and that notification is documented in the electronic health records and that compliance be monitored.
Closure Date:
10 We recommended that processes be strengthened to ensure that safety plans contain documentation of assessment of available lethal means and ways to keep the environment safe and that compliance be monitored.
Closure Date:
11 We recommended that processes be strengthened to ensure that patients and/or their families receive a copy of the safety plan and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that written agreements acknowledging resident responsibility for medication security are in place in the domiciliary and the Domiciliary Care for Homeless
Closure Date:
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15039