Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 13-02312-304 | Combined Assessment Program Review of the Cheyenne VA Medical Center, Cheyenne, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that
the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
2 We recommended that all required members participate in
Transfusion Review/Lab Utilization Review Committee meetings.
Closure Date:
3 We recommended that the facility establish a policy for pressure
ulcer prevention, establish an interprofessional pressure ulcer committee, and ensure that the interprofessional pressure ulcer committee reports program data to facility executive leadership.
Closure Date:
4 We recommended that processes be strengthened to ensure that
acute care staff perform and document a complete skin inspection and risk scale at
discharge and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that acute care staff accurately document location, stage, and/or risk scale score for all patients with pressure ulcers and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that acute care staff perform and document daily risk scales for patients at risk for or with pressure ulcers and that compliance be monitored.
Closure Date:
7 We recommended that the facility establish patient/caregiver and staff pressure ulcer education requirements and that compliance be monitored.
Closure Date:
8 We recommended that the facility fully implement the nurse staffing methodology.
Closure Date:
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| 13-01550-286 | Inspection of VA Regional Office St. Paul, Minnesota | Review | ||
1 We recommend the St. Paul VA Regional Office Director conduct a review of the 299 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommend the St. Paul VA Regional Office Director provide refresher training on processing traumatic brain injury claims and develop and implement a plan to monitor the effectiveness of that training.
Closure Date:
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| 13-02257-294 | Inspection of VA Regional Office Togus, Maine | Review | ||
1 We recommend the Togus VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examinations to obtain the evidence required to support traumatic brain injury evaluations.
Closure Date:
2 We recommend the Togus VA Regional Office Director develop and implement a plan to ensure staff completely and timely address all required elements of Systematic Analyses of Operations.
Closure Date:
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| 12-04631-313 | Healthcare Inspection - Gastroenterology Consult Delays, William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina | Hotline Healthcare Inspection | ||
1 We recommend that, in accordance with the Administrative Investigation Board conclusions and recommendations, Veterans Integrated Service Network leaders take appropriate action in relationship to leadership deficits contributing to the gastroenterology consult backlog.
Closure Date:
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| 12-00181-299 | Audit of VBA's Pension Payments | Audit | ||
1 We recommended the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements procedures that ensure continued veteran and beneficiary eligibility.
Closure Date:
2 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements a plan to reduce the amount of underpayments and overpayments due to changes in income and dependency.
Closure Date:
3 We recommend the Under Secretary for Benefits implement the use of the enhanced interagency exchange agreements with the Internal Revenue Service and Social Security Administration to reduce delays in verifying veteran and beneficiary reported income.
Closure Date:
4 We recommended the Under Secretary for Benefits establish a matching program with Medicaid to automatically identify veterans and beneficiaries that require nursing home adjustments.
Closure Date:
5 We recommend the Under Secretary for Benefits ensure the Pension Management Centers clearly outline processing priorities in their workload management plans.
Closure Date:
6 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service implements its plan to revise triage procedures and establish processing lanes to ensure prompt screening and routing of claims.
Closure Date:
7 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service corrects the duplicate records identified in this audit.
Closure Date:
8 We recommend the Under Secretary for Benefits ensure the Pension and Fiduciary Service requests an additional data test be added to their current series of data tests that would identify claimant records with similar or same names under the same
file number.
Closure Date:
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| 13-01351-296 | Healthcare Inspection – Alleged Sterile Processing Service Deficiencies, VA Puget Sound Health Care System, Seattle, Washington | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure that Sterile Processing Service has a process in place to identify single-use devices and mitigate the risk of single-use devices being resterilized.
Closure Date:
2 We recommended that the System Director ensure that processes be strengthened to ensure that Sterile Processing Service staff competency records are well organized and that managers are able to readily determine the current competence of each person on each task.
Closure Date:
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| 12-04326-275 | Inspection of VA Regional Office Muskogee, Oklahoma | Review | ||
1 We recommend the Muskogee VA Regional Office Director conduct a review of the 304 temporary 100 percent disability evaluations remaining from our inspection universe.
Closure Date:
2 We recommend the Muskogee VA Regional Office Director provide refresher training on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of the training.
Closure Date:
3 We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure accurate second-signature reviews of traumatic brain injury claims.
Closure Date:
4 We recommend the Muskogee VA Regional Office Director develop and implement a plan to ensure Rating Veterans Service Representatives correctly address Gulf War veterans' entitlement to mental health treatment as required.
Closure Date:
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| 13-00026-302 | Community Based Outpatient Clinic Reviews at Chillicothe VA Medical Center, Chillicothe, OH | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that patients with normal cervical cancer screening results are notified of results within the required timeframe and that notification is documented in the EHR.
Closure Date:
2 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
3 We recommended that managers ensure that clinicians document all required tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
4 We recommended that a written inventory of hazardous materials is maintained.
Closure Date:
5 We recommended that all identified EOC deficiencies are tracked, trended, and corrected.
Closure Date:
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| 13-00993-274 | Inspection of VA Regional Office Albuquerque, New Mexico | Review | ||
1 We recommend the Albuquerque VA Regional Office Director conduct a review of the 190 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
2 We recommend the Albuquerque VA Regional Office Director conduct refresher training on processing traumatic brain injury claims and implement a plan to monitor the effectiveness of this training.
Closure Date:
3 We recommend the Albuquerque VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to obtain the evidence required to support traumatic brain injury evaluations.
Closure Date:
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| 13-01625-273 | Inspection of VA Regional Office Newark, New Jersey | Review | ||
1 We recommend the Newark VA Regional Office Director develop and implement a plan to ensure claims processing staff take timely actions to finalize reductions in benefits.
Closure Date:
2 We recommend the Newark VA Regional Office Director develop and implement a plan to review the 149 temporary 100 percent disability evaluations remaining from our inspection universe and take appropriate action.
Closure Date:
3 We recommend the Newark VA Regional Office Director develop and implement a plan to ensure effective second-signature reviews of traumatic brain injury claims decisions.
Closure Date:
4 We recommend the Newark VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers within the VA Regional Office's jurisdiction.
Closure Date:
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15039