Recommendations
2099
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00539-221 | A Select Review of VHA’s Implementation of the VA Sustainability Plan | National Healthcare Review | ||
1 The Secretary of Veterans Affairs considers incorporating environmental stewardship values into the goals of the Climate- and Sustainability-Focused Federal Workforce priority action in the VA Sustainability Plan to align with Executive Order 14057.
Closure Date:
2 The Under Secretary for Health evaluates the facility-level Green Environmental Management System program manager position, and determines the position’s responsibilities, if any, in the implementation of the VA Sustainability Plan.
Closure Date:
3 The Under Secretary for Health considers broadening the scope of training, education, and engagement of Veterans Health Administration’s workforce to include and incorporate environmental stewardship values.
Closure Date:
4 The Under Secretary for Health encourages continued efforts by the Veterans Health Administration National Anesthesia Service to track and reduce greenhouse gas emissions from inhalational anesthetics and considers evaluation and implementation of a comprehensive waste anesthetic gas mitigation strategy, in pursuit of the VA Sustainability Plan’s priority action goal of achieving net-zero greenhouse gas emissions by 2045.
Closure Date:
5 The Under Secretary for Health considers the relative merits of single-use versus reusable medical devices and evaluates current Veterans Health Administration policy that prohibits the repurposing of single-use medical devices by VA medical centers to increase landfill waste diversion.
Closure Date:
| ||||
| 23-03531-218 | Failures by Telemetry Medical Instrument Technicians and Leaders’ Response at the VA Eastern Colorado Health Care System in Aurora | Hotline Healthcare Inspection | ||
1 The VA Eastern Colorado Health Care System Director evaluates and ensures that telemetry medical instrument technicians and registered nurses comply with Veterans Health Administration and facility policy requirements for documentation and scanning, specifically related to telemetry oxygenation and rhythm strips and change in patient condition.
2 The VA Eastern Colorado Health Care System Director in conjunction with telemetry nursing leaders, ensures completion of a comprehensive review of the telemetry program and documented oversight of compliance with medical instrument technician monitoring expectations, identifies deficiencies, and takes actions as warranted.
Closure Date:
3 The VA Eastern Colorado Health Care System Director promotes and encourages all staff to use the Joint Patient Safety Reporting system to report patient safety events and ensures telemetry staff and managers are trained on the use of the Joint Patient Safety Reporting system.
Closure Date:
4 The VA Eastern Colorado Health Care System Director evaluates and ensures quality and patient safety event review processes comply with Veterans Health Administration guidance, specifically regarding rejection and follow-up of patient safety reports.
Closure Date:
5 The VA Eastern Colorado Health Care System Director and facility leaders meet all Veterans Health Administration requirements for institutional disclosures for events meeting institutional disclosure criteria.
Closure Date:
6 The VA Eastern Colorado Health Care System Director ensures review of facility clinical alarm management and committee processes, identifies deficiencies, and takes actions as warranted.
Closure Date:
| ||||
| 23-00749-171 | Unauthorized Community Care Dental Procedures Risked Improper Payments | Audit | ||
1 Ensure all community dentists who provide dental care to veteran patients are notified and periodically reminded of the preauthorization requirements for any changes to treatment plans.
Closure Date:
2 Conduct expanded postpayment reviews to identify and recover payments for unauthorized dental procedures.
Closure Date:
3 Monitor VA dentists to make sure they include required dental procedure codes, not only general descriptions or Standardized Episodes of Care, on referrals to identify the procedures community dentists are authorized to perform.
Closure Date:
4 Review the current contract language and determine if there is a need to clarify the third-party administrators’ claims adjudication responsibilities in its contracts to include the identification of unauthorized dental procedures and adjudication of possible denials of payment or implement controls within VA that will perform this adjudication function for dental claims.
5 Enable the Office of Finance’s automated payment system to deny payment for community dental services if the procedure codes on the dental claims do not fall within the Standardized Episodes of Care on the referral.
| ||||
| 24-00160-212 | Deficiencies in Informed Consent for Admission and Against Medical Advice Discharge Processes for a Patient at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director develops a process consistent with Veterans Health Administration Directive 1004.01(3) to ensure patients are informed, prior to voluntary admission to the inpatient mental health unit, that the unit is locked and provides services to patients with mental health disorders.
Closure Date:
2 The VA Southern Nevada Healthcare System Director ensures staff are educated following development of the informed consent process for voluntary admission to the inpatient mental health unit.
Closure Date:
3 The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 adheres to Nevada state law relevant to admission to mental health units and is approved in accordance with Veterans Health Administration policies.
Closure Date:
4 The VA Southern Nevada Healthcare System Director confirms that medical center policy 116-22-10 includes the responsible owners’ oversight and guidance responsibilities as required by Veterans Health Administration Directive 0999(1).
Closure Date:
5 The VA Southern Nevada Healthcare System Director ensures staff education regarding changes to the medical center policy 116-22-10.
Closure Date:
6 The VA Southern Nevada Healthcare System Director ensures that any facility policies involving state law addressing voluntary or involuntary mental health commitments be reviewed by the Office of General Counsel.
Closure Date:
7 The VA Southern Nevada Healthcare System Director develops a process to ensure facility policies adhere to the Veterans Health Administration Directive 0999(1), medical center policy standardized template.
Closure Date:
| ||||
| 23-01601-208 | Insufficient Mental Health Treatment and Access to Care for a Patient and Review of Administrative Actions in Veterans Integrated Service Network 10 | Hotline Healthcare Inspection | ||
1 The Ann Arbor VA Medical Center Director conducts a full review of the patient’s spring to fall 2017 mental health care to identify quality of care improvement opportunities related to inpatient psychiatrist 2’s medical decision-making, staff’s pre-discharge outpatient care planning, and outpatient staff’s collaboration in providing treatment and engagement efforts including the mental health treatment coordinator assignment and role, and takes actions as warranted.
Closure Date:
2 The Battle Creek VA Medical Center Director ensures staff awareness and access to eligibility verification procedures.
Closure Date:
3 The Battle Creek VA Medical Center Director expedites the full implementation of the Transfer and Admission Coordination Office including a centralized phone number and monitors compliance with the standardized checklist.
Closure Date:
4 The Battle Creek VA Medical Center Director expedites the completion and implementation of the interfacility transfers standard operating procedure and monitors compliance.
Closure Date:
5 The Battle Creek VA Medical Center Director ensures the mental health residential rehabilitation treatment program standard operating procedure is aligned with Veterans Health Administration requirements regarding referral and monitors compliance.
Closure Date:
6 The Veterans Integrated Service Network Director evaluates the efficacy of the Interagency Resolution Council and identification of clearly defined objectives and processes to monitor progress and address identified barriers.
Closure Date:
| ||||
| 23-00776-207 | Delays and Deficiencies in the Mental Health Care of a Patient at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The VA Houston Health Care System Director evaluates the efficiency of evidence-based psychotherapy consult management procedures; identifies barriers to timely appointment scheduling, including scheduling processes and staffing needs; and takes action as warranted.
Closure Date:
2 The VA Houston Health Care System Director ensures that administrative support staff document scheduling efforts in patients’ electronic health records, as required by the Veterans Health Administration.
Closure Date:
3 The VA Houston Health Care System Director ensures that staff document offering VA-issued devices for participation in virtual mental health appointments in patients’ electronic health records.
Closure Date:
4 The VA Houston Health Care System Director conducts a review of providers’ lethal means safety assessment and planning with the patient, identifies barriers to effective lethal means safety discussions, and takes action as warranted.
Closure Date:
5 The Under Secretary for Health clarifies the expectations and requirements for homeless program staff’s completion of suicide risk assessments and updates or reviews of safety plans for high risk for suicide patients.
Closure Date:
6
The VA Houston Health Care System Director reviews staff’s compliance with high-risk flag patient care requirements, to include updating and reviewing safety plans, following up on failed contacts, and completing suicide risk assessments.
Closure Date:
| ||||
| 23-03159-204 | Inadequate Care of a Patient Who Died by Suicide on a Medical Unit at the Sheridan VA Medical Center in Wyoming | Hotline Healthcare Inspection | ||
1 The Sheridan VA Medical Center Director ensures completion of warm handoffs and Comprehensive Suicide Risk Evaluations within 24 hours for patients on the medical unit that screen positive on the Columbia-Suicide Severity Rating Scale.
Closure Date:
2 The Sheridan VA Medical Center Director ensures that psychiatry or medical officer of the day staff reassess suicidal patients prior to changing a one-to-one observation status order.
3 The Sheridan VA Medical Center Director ensures that inpatient notes are completed and authenticated by providers as soon as possible, but always within 24 hours, in accordance with facility policy.
Closure Date:
4 The Sheridan VA Medical Center Director ensures that staff follow facility policies for removing belongings and environmental risks for suicidal patients on one-to-one observation status on the medical unit.
Closure Date:
| ||||
| 23-02958-203 | Care Concerns and Deficiencies in Facility Leaders’ and Staff’s Responses Following a Medical Emergency at the Carl T. Hayden VA Medical Center in Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System rapid response policy is in alignment with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.
Closure Date:
2 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policies and procedures related to responding to medical emergencies do not conflict.
Closure Date:
3 The Phoenix VA Health Care System Director ensures Phoenix VA Health Care System policy is in alignment with Veterans Health Administration Directive 1101.14, Emergency Medicine.
Closure Date:
4 The Phoenix VA Health Care System Director ensures layperson cardiopulmonary resuscitation training is offered in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation.
Closure Date:
5 The Phoenix VA Health Care System Director determines the need for, and implements placement of, public access automated external defibrillators in accordance with Veterans Health Administration Directive 1177, Cardiopulmonary Resuscitation
Closure Date:
6 The Phoenix VA Health Care System Director assesses outpatient clinic compliance with vital sign completion and documentation, identifies deficiencies, and takes action as warranted.
Closure Date:
7 The Phoenix VA Health Care System Director reviews and assesses the need for non-clinical staff training on the use of the Joint Patient Safety Reporting system, and takes action as warranted.
Closure Date:
8 The Phoenix VA Health Care System Director ensures complaints are reviewed and addressed in accordance with Veterans Health Administration Directive 1003.04, VHA Patient Advocacy.
Closure Date:
9 The Phoenix VA Health Care System Director reviews organizational communication channels and ensures consistency with Veterans Health Administration high reliability organization principles and I CARE values
Closure Date:
10 The Phoenix VA Health Care System Director makes certain that investigation and closure of events placed into the Joint Patient Safety Reporting system are completed per the Veterans Health Administration’s established time frame, and monitors compliance.
| ||||
| 23-00995-211 | Mismanaged Surgical Privileging Actions and Deficient Surgical Service Quality Management Processes at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director conducts focused clinical care reviews in accordance with Veterans Health Administration requirements, and monitors for compliance.
2 The Hampton VA Medical Center Director ensures that summary suspensions are conducted in accordance with Veterans Health Administration policy, and monitors for compliance.
3 The Hampton VA Medical Center Director confirms that proposed reduction or revocation of privileges complies with Veterans Health Administration policies and procedures, and monitors for compliance.
4 The Hampton VA Medical Center Director complies with Veterans Health Administration requirements when reporting licensed independent practitioners to state licensing boards.
5 The Hampton VA Medical Center Director completes a review of Medical Executive Committee meeting minutes and ensures recommendations made for focused professional practice evaluations for cause for licensed independent practitioners have been completed according to Veterans Health Administration requirements.
6 The Hampton VA Medical Center Director ensures that, when providers are transitioned from an initial focused professional practice evaluation to an ongoing professional practice evaluation, the transition is reported and documented as required by Veterans Health Administration policy, and monitors for compliance.
7 The Hampton VA Medical Center Director ensures that ongoing professional practice evaluations include documentation of all conclusionary outcomes required by Veterans Health Administration policy.
8 The Hampton VA Medical Center Director ensures surgical staff have an understanding of Veterans Health Administration Joint Patient Safety Reporting submissions and tracks submissions specific to Surgical Service, and monitors for compliance.
Closure Date:
9 The Hampton VA Medical Center Director completes a comprehensive review of surgical morbidity and mortality conferences and ensures facility policy and practice is in alignment with Veterans Health Administration policy and, as necessary, consults with Veterans Health Administration’s National Surgery Office and Veterans Integrated Service Network leaders, and monitors for compliance.
Closure Date:
10 The Hampton VA Medical Center Director ensures that the chief of surgery has a process to identify potential cases for peer review and communicates those cases to the appropriate program staff.
Closure Date:
11 The Mid-Atlantic Veterans Integrated Service Network Director confirms the Hampton VA Medical Center Director ensures that management reviews and peer reviews, if both indicated for the same incident of care, are conducted in accordance with Veterans Health Administration policy, and are not conducted concurrently.
Closure Date:
12 The Hampton VA Medical Center Director considers seeking guidance from the Office of General Counsel to determine the appropriate time frame for ensuring all required elements for previously completed institutional disclosures have been met.
Closure Date:
| ||||
| 23-01772-162 | VBA Needs to Improve the Accuracy of Decisions for Total Disability Based on Individual Unemployability | Review | ||
1 Update guidance mandating use of an effective date builder for rating veterans service representatives to consider earlier effective dates when granting entitlement to individual unemployability.
2 Develop standardized language and prioritize incorporation into the Veterans Benefits Management System to assist rating veterans service representatives in addressing all required information/elements within an individual unemployability rating narrative.
Closure Date:
3 Establish additional system controls to ensure rating veterans service representatives address competency when individual unemployability has been awarded based solely on a mental condition.
4 Update the Veterans Benefits Administration’s procedures manual to ensure consistency among staff and clarify the language needed to satisfy the analysis requirement when granting entitlement to individual unemployability benefits.
Closure Date:
5 Develop practical learning exercises for rating veterans service representatives related to individual unemployability for Virtual and In-Person Progression training.
Closure Date:
6 Require rating veterans service representatives and veterans service representatives to process and demonstrate individual unemployability claim competency on veterans’ claims.
Closure Date:
7 Evaluate the workload distribution methods for individual unemployability claims to increase claims processing consistency and knowledge retention.
Closure Date:
| ||||
15137