Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03939-175 | Healthcare Inspection - Alleged Inappropriate Surveillance James A. Haley Veterans’ Hospital Tampa, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the Under Secretary for Health ensures that VHA policy addresses the clinical uses of covert and overt video surveillance cameras in a clinical setting, including public notification, informed consent, approval, and responsibility for use of these devices, as well as detail procedures for staff to follow in obtaining video recordings for teaching, patient care and treatment, patient safety, healthcare operations, general security, and law enforcement purposes. Restrictions on the use of personal electronic devices within a VA facility to photograph and video should also be considered.
Closure Date:
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| 13-00026-166 | Community Based Outpatient Clinic Reviews at Dayton VA Medical Center, Dayton, 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 defined 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 pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
4 We recommended that managers ensure that the facility policy for semi-annual EOC rounds includes the CBOCs and that EOC meeting minutes reflect sufficient discussion of CBOCs' issues, deficiencies, and items.
Closure Date:
5 We recommended that managers ensure that staff are trained and knowledgeable of the local CBOC medical and MH emergency policy.
Closure Date:
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| 12-03475-169 | Inspection VA Regional Office Philadelphia, Pennsylvania | Review | ||
1 We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure compliance with Veterans Benefits Administration policy regarding timely benefits reduction actions.
Closure Date:
2 We recommend the Philadelphia VA Regional Office Director provide refresher training to ensure staff establish suspense diaries for temporary 100 percent.
Closure Date:
3 We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure staff return insufficient medical examination reports to health care facilities to obtain the required evidence needed to support traumatic brain injury claims.
Closure Date:
4 We recommend the Philadelphia VA Regional Director develop and implement a plan to ensure staff compliance with Veterans Benefits Administration second signature requirements for processing traumatic brain injury claims.
Closure Date:
5 We recommend the Philadelphia VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly provide outreach to homeless shelters and service providers.
Closure Date:
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| 13-00278-164 | Combined Assessment Program Review of the Dayton VA Medical Center, Dayton, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired LIPs are consistently initiated and that results are consistently reported to the PSB.
Closure Date:
2 We recommended that the scanning quality control process includes all required elements.
Closure Date:
3 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
4 We recommended that processes be strengthened to ensure that clinicians perform and document patient assessments following blood product transfusions.
Closure Date:
5 We recommended that processes be strengthened to ensure that code evaluation sheets are completed for all code episodes.
Closure Date:
6 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect sufficient discussion of findings, action plans, and tracking of items to closure.
Closure Date:
7 We recommended that managers initiate actions to address the 12 identified deficiencies and that processes be strengthened to ensure that all deficiencies identified during annual physical security surveys are corrected.
Closure Date:
8 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
9 We recommended that a process be established to track HPC consults that are not acted upon within the requested timeframe.
Closure Date:
10 We recommended that processes be strengthened to ensure that HPC inpatients' pain is consistently assessed and results documented in EHRs and that compliance be monitored.
Closure Date:
11 We recommended that managers initiate protected peer review for the three identified patients and complete any recommended review actions.
Closure Date:
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| 11-00331-160 | Audit of the Community Nursing Home Program | Audit | ||
1 We recommended the Under Secretary for Health ensure Veterans Health Administration community nursing home policies are updated and reissued.
Closure Date:
2 We recommended the Under Secretary for Health conduct a comprehensive national review of nursing homes to ensure veterans are not placed in any nursing homes deemed ineligible by Veterans Health Administration policy, and take appropriate remedial action where necessary.
Closure Date:
3 We recommended the Under Secretary for Health implement a formal oversight and communication process to ensure healthcare facilities comply with Veterans Health Administration nursing home policy and perform proper eligibility reviews.
Closure Date:
4 We recommended the Under Secretary for Health establish a monitoring mechanism to ensure the Office of Geriatrics and Extended Care Strategic Healthcare Group, and healthcare facilities, use the Community Nursing Home Certification Report to monitor the nursing home program and identify high-risk nursing homes.
Closure Date:
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| 13-00026-157 | Community Based Outpatient Clinic Reviews at VA Palo Alto Health Care System, Palo Alto, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
Closure Date:
2 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
Closure Date:
3 We recommended that testing of the panic alarm system is documented at the Monterey CBOC.
Closure Date:
4 We recommended that patients' PII are secured and protected at the Monterey CBOC.
Closure Date:
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| 11-02487-158 | Healthcare Inspection - Evaluation of Cataract Surgeries and Outcomes in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, monitor and ensure consistent verification and documentation of preoperative intraocular lens implant verification in the electronic health record for all cataract surgeries.
Closure Date:
2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure the analysis of OSOD data and dissemination of associated quality improvement processes to VA cataract surgery facilities.
Closure Date:
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| 12-03629-139 | Inspection of VA Regional Office Nashville, Tennessee | Review | ||
1 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record to support scheduling of medical reexaminations.
Closure Date:
2 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure claims processing staff take accurate and timely actions to propose or finalize reductions in benefits.
Closure Date:
3 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure accurate second signature reviews of traumatic brain injury claims decisions.
Closure Date:
4 We recommend the Nashville 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 under the VA Regional Office's jurisdiction.
Closure Date:
5 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure staff accurately identify and expedite processing and monitoring of all homeless veterans' claims.
Closure Date:
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| 13-00279-156 | Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are clearly defined and consistently tracked to completion at the service level.
Closure Date:
2 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
Closure Date:
3 We recommended that processes be strengthened to ensure that the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria are reported to the Transfusion Review Committee.
Closure Date:
4 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
Closure Date:
5 We recommended that processes be strengthened to ensure that sharps containers in the Menlo Park CLC are readily accessible to all staff.
Closure Date:
6 We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that expired multi-dose vials are removed from medication carts in the CLC.
Closure Date:
8 We recommended that the facility fully implement the nurse staffing methodology.
Closure Date:
9 We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
Closure Date:
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| 12-02503-151 | Administrative Investigation, Misuse of Official Time and Resources and Failure to Properly Supervise, Office of Human Resources and Administration, Washington, DC | Administrative Investigation | ||
1 We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take against [redacted] and ensure that action is taken.
Closure Date:
2 We recommend that the Acting Assistant Secretary for Human Resources and Administration determine the total salary paid to [redacted] for the 39 days that [redacted] was AWOL from VA or worked for [redacted] while on sick leave and ensure that a bill of collection is issued to [redacted] for that amount, since [redacted] cannot receive pay for the period of time that [redacted] was absent without authorization.
Closure Date:
3 We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with OHR and OGC to determine the appropriate administrative action to take against Mr. Viani and ensure that action is taken.
Closure Date:
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14917