Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00096-122 | Comprehensive Healthcare Inspection of the VA Central Iowa Health Care System in Des Moines | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete licensed independent practitioners’ Ongoing Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based, in part, on Ongoing Professional Practice Evaluation activities.
Closure Date:
3 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00967-64 | Veteran Readiness and Employment Staff Improperly Sent Participants to Veteran Employment Through Technology Education Courses | Review | ||
1 Develop and implement policies and system controls to ensure all programs approved for use by vocational rehabilitation counselors for Veteran Readiness and Employment participants meet the requirements of applicable laws and regulations
Closure Date:
2 Train all appropriate Veteran Readiness and Employment regional office staff on manual requirement to verify the programs are approved for use before selecting participants and to verify facility codes match from authorization through enrollment.
Closure Date:
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| 23-00097-113 | Comprehensive Healthcare Inspection of the VA Black Hills Health Care System in Fort Meade, South Dakota | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for each licensed independent practitioner.
Closure Date:
2 The Chief of Staff ensures the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluation data and documents its review prior to recommending licensed independent practitioners’ ongoing privileges to the Director.
Closure Date:
3 The Director ensures staff complete environment of care inspections at the required frequency.
Closure Date:
4 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-00122-118 | Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures medical staff review and document licensed independent practitioners’ Focused Professional Practice Evaluation results and report them to the Medical Executive Board.
Closure Date:
2 The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by regularly conducting Ongoing Professional Practice Evaluations.
Closure Date:
3 The Medical Center Director ensures staff conduct environment of care inspections in patient care areas at the required frequency.
Closure Date:
4 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events to mental health leaders and quality management staff at least monthly.
Closure Date:
5 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 22-03164-106 | Comprehensive Healthcare Inspection of the VA Ann Arbor Healthcare System in Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 22-03167-110 | Comprehensive Healthcare Inspection of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-01450-114 | Electronic Health Record Modernization Caused Pharmacy-Related Patient Safety Issues Nationally and at the VA Central Ohio Healthcare System in Columbus | Hotline Healthcare Inspection | ||
1 The Deputy Secretary ensures mitigation of the high-risk pharmacy-related patient safety issues identified during the May 2021 National Center for Patient Safety visit.
Closure Date:
2 The Under Secretary for Health evaluates whether the new electronic health record reflects accurate patient medication information per Veterans Health Administration requirements and takes action as indicated.
Closure Date:
3 The Deputy Secretary ensures the resolution of pharmacy-related usability issues identified in this report.
Closure Date:
4 The Deputy Secretary ensures correction of inaccurate medication data transmitted to the Health Data Repository.
Closure Date:
5 The Under Secretary for Health determines the need for and implements a comprehensive strategy to review patients affected by inaccurate medication data transmitted to the Health Data Repository to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of institutional disclosures.
Closure Date:
6 The Under Secretary for Health ensures patients affected by inaccurate medication data transmitted to the Health Data Repository are notified of the risk of harm per Veterans Health Administration requirements.
Closure Date:
7 The Under Secretary for Health ensures legacy site providers are aware of mitigations needed for patients previously treated at a new electronic health record site and monitors compliance.
Closure Date:
8 The Under Secretary for Health ensures that pharmacist staffing levels are assessed and addressed prior to the implementation of the new electronic health record at additional VA sites
Closure Date:
9 The Under Secretary for Health evaluates the underlying technical and functional issues resulting in workarounds and educational materials needed to perform pharmacy-related operations within the new electronic health record and takes action as indicated.
Closure Date:
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| 23-00382-100 | Scheduling Error of the New Electronic Health Record and Inadequate Mental Health Care at the VA Central Ohio Healthcare System in Columbus Contributed to a Patient Death | Hotline Healthcare Inspection | ||
1 The Deputy Secretary establishes ongoing monitors to ensure that scheduling procedures in the new electronic health record are functioning in accordance with Veterans Health Administration requirements.
Closure Date:
2 The Under Secretary for Health evaluates minimum scheduling effort requirements for mental health appointments and takes action to ensure the implementation of standardized policy and procedures in the best interest of patient care.
3 The VA Central Ohio Healthcare System Medical Center Director conducts a full review of the care of the patient provided by the nurse practitioner and psychologist 1, and the supervisory psychologist’s oversight, consults with Human Resources and General Counsel Offices, and takes actions as warranted.
Closure Date:
4 The VA Central Ohio Healthcare System Medical Center Director ensures compliance with the Caring Communication Program including the initiation and cessation of caring communications as required.
Closure Date:
5 The Under Secretary for Health considers establishing written guidance related to documentation, leaders’ review, follow-up actions, and tracking of Lessons Learned in root cause analyses.
Closure Date:
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| 23-01746-112 | Inadequacies in Patient Safety Reporting Processes and Alleged Deficient Quality of Care Prior to a Patient’s Foot Amputation at the Edward Hines, Jr. VA Hospital in Hines, Illinois | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures that patient advocacy staff within Veterans Integrated Service Network 12 are educated on the need to consult with patient safety staff when complaints involve patient safety concerns.
Closure Date:
2 The Edward Hines, Jr. VA Hospital Director ensures a review is completed of the missed opportunities referenced in this report related to refitting and reeducating patients on VA-issued shoes, determines the need to create a related standard operating procedure or facility policy, and takes action as necessary.
Closure Date:
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| 23-06147-111 | Logistics Managers Improperly Allowed Employees to Auction Off Government Property | Administrative Investigation | ||
1 Ensure the DALC Recreation Group’s operations fully comply with VA Handbook 5025, Part VIII, or dissolve the group if there is insufficient employee interest in its continuation.
Closure Date:
2 Update VA Handbook 7002, Logistics Management Procedures Part 3, section 7, to clarify under which circumstances, if any, VA employees are permitted to request, accept, and record any incentive items provided by vendors in connection with government purchases.
Closure Date:
3 Reinforce ethics and policy requirements on the acceptance and disposition of free or donated property with all Denver Logistics Center managers and staff, including distributing to staff the Office of General Counsel’s guidance dated June 30, 2023.
Closure Date:
4 Reeducate DLC managers, approving officials, and purchasing agents about VA government purchase card policy requirements that government contracted sources be fully considered and given priority when making purchases.
Closure Date:
5 In consultation with the Office of General Counsel, as authorized by 31 U.S.C. § 3711, determine the full magnitude of the loss from the DALC Recreation Group’s improper sale of VA property and take appropriate action to recover the losses, including any proceeds of the auctions currently within the custody or control of the DALC Recreation Group.
Closure Date:
6 Consider whether any administrative action should be taken with respect to the conduct or performance of the director of the Denver Logistics Center or any other individual involved in the improper acquisition and disposition of the incentive items, and report to the OIG any actions taken involving these individuals.
Closure Date:
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14921