Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03355-88 | Inspection of the VA Regional Office, Detroit, Michigan | Review | ||
1 We recommend the Detroit VA Regional Office Director provide training and implement controls to ensure staff follow current Veterans Benefits Administration policy on scheduling medical reexaminations for temporary 100 percent evaluations.
Closure Date:
2 We recommend the Detroit 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 rating decisions.
Closure Date:
3 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure Veterans Service Center staff follow Veterans Benefits Administration policy on proper establishment of dates of claim.
Closure Date:
4 We recommend the Detroit VA Regional Office Director amend the local Workload Management Plan to include specific requirements for management oversight and review to improve claims processing timeliness.
Closure Date:
5 We recommend the Detroit VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations.
Closure Date:
6 We recommend the Detroit VA Regional Office Director develop and implement a plan to monitor the effectiveness of training to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War veterans' entitlement to mental health treatment when denying service connection for mental disorders.
Closure Date:
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| 11-04359-80 | Review of VHA's South Texas Veterans Health Care System's Management of Fee Care Funds | Audit | ||
1 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for clinical and fee staff to properly process authorizations for fee care.
Closure Date:
2 We recommended the Director of the Veterans Integrated Service Network ensure standard operating procedures clearly define roles and responsibilities and the procedures required for fee staff to process payments of vendor invoices timely.
Closure Date:
3 We recommended the Director of the South Texas Veterans Health Care System ensure clinical and fee staff receive periodic training on fee care procedures.
Closure Date:
4 We recommended the Director of the South Texas Veterans Health Care System establish independent oversight mechanisms, such as periodic audits or reviews by the Compliance Officer, to ensure that newly established procedures at the South Texas Veterans Health Care System are followed to properly control and manage funds for its fee care program.
Closure Date:
5 We recommended the Director of the Veterans Integrated Service Network establish independent oversight mechanisms, such as periodic audits or reviews, to ensure that procedures for properly controlling and managing fee care program funds are followed at the South Texas Veterans Health Care System.
Closure Date:
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| 12-04214-83 | Healthcare Inspection – Emergency Department Evaluation of a Homeless Veteran VA North Texas Health Care System, Dallas, Texas | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director ensure that the facility develops a written SOP for emergency department patient flow and orientation is provided to all emergency department staff and on-call personnel.
Closure Date:
2 We recommended that the Facility Director ensure that EDIS is used as required.
Closure Date:
3 We recommended that the Facility Director ensure that SW services are provided in the emergency department as required.
Closure Date:
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| 12-02602-79 | Combined Assessment Program Review of the Huntington VA Medical Center,Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 We recommended that PR analysis summary reports be discussed quarterly at the ECMS and that the discussion be documented in meeting minutes.
Closure Date:
2 We recommended that processes be strengthened to ensure that results from FPPEs are consistently reported to the ECMS.
Closure Date:
3 We recommended that the facility develop a local policy mandating a Cardiopulmonary Resuscitation Committee.
Closure Date:
4 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
Closure Date:
5 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
Closure Date:
6 We recommended that processes be strengthened to ensure that smoking occurs in designated areas only.
Closure Date:
7 We recommended that processes be strengthened to ensure that staff are able to locate MSDS for hazardous chemicals used in their areas.
Closure Date:
8 We recommended that the annual staffing plan reassessment process ensures that each unit has a unit-based expert panel and that each panel includes members from all nursing roles.
Closure Date:
9 We recommended that the annual staffing plan reassessment process ensures that all required staff are facility expert panel members.
Closure Date:
10 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
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| 12-03744-84 | Combined Assessment Program Review of the Central Texas Veterans Health Care System, Temple, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that results of FPPEs for newly hired licensed independent practitioners are consistently reported to the Medical Staff Executive Committee.
Closure Date:
2 We recommended that processes be strengthened to ensure that the blood usage and review process includes the results of proficiency testing.
Closure Date:
3 We recommended that processes be strengthened to ensure that conversions from observation bed status to acute admissions are consistently 30 percent or less.
Closure Date:
4 We recommended that processes be strengthened to ensure that patient care areas are clean and well maintained and clean and dirty supplies are stored separately and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that damaged furniture in patient care areas is repaired or removed from service and that the facility be well maintained.
Closure Date:
6 We recommended that processes be strengthened to ensure that damaged therapy mats in the Temple division physical therapy clinic are repaired or removed from service.
Closure Date:
7 We recommended that processes be strengthened to ensure that all required non-pharmacy areas with CS are inspected and that compliance be monitored.
Closure Date:
8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated MH provider and an administrative support person.
Closure Date:
9 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
Closure Date:
10 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
Closure Date:
11 We recommended that managers initiate a protected peer review for the three identified patients and complete any recommended review actions.
Closure Date:
12 We recommended that processes be strengthened to ensure that all required participants or their designees consistently attend EOC rounds.
Closure Date:
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| 12-03740-75 | Combined Assessment Program Review of the Durham VA Medical Center, Durham, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the local observation bed policy be revised to include all required elements.
Closure Date:
2 We recommended that processes be strengthened to ensure that data about observation bed use is gathered.
Closure Date:
3 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
Closure Date:
4 We recommended that the quality control policy for scanning be revised to include image quality, linking of scanned documents to the correct record, and indexing the documents.
Closure Date:
5 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
Closure Date:
6 We recommended that processes be strengthened to ensure that required members from surgery and medicine attend Transfusion Committee meetings.
Closure Date:
7 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
Closure Date:
8 We recommended that managers initiate protected peer review for the two identified patients and complete any recommended review actions.
Closure Date:
9 We recommended that processes be strengthened to ensure that contractor tuberculosis skin test results for all projects are documented.
Closure Date:
10 We recommended that processes be strengthened to ensure that Construction Safety Committee minutes contain documentation of deficiencies and follow-up actions in response to unsafe conditions identified during inspections.
Closure Date:
11 We recommended that processes be strengthened to ensure that Material Safety Data Sheets for chemicals used in construction sites are located within the construction areas.
Closure Date:
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| 12-02089-60 | Inspection of the VA Regional Office Anchorage, Alaska | Review | ||
1 We recommend the Anchorage VA Regional Office Director develop and implement a plan to monitor proposed disability evaluation reduction processing actions.
Closure Date:
2 We recommend the Anchorage 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:
3 We recommend the Anchorage VA Regional Office Director develop and implement a plan to assess the effectiveness of training for properly processing traumatic brain injury claims.
Closure Date:
4 We recommend the Anchorage VA Regional Office Director develop and implement controls to ensure management follows the Veterans Benefits Administration's policy and workload management plan for all claims pending for more than 1 year.
Closure Date:
5 We recommend the Anchorage VA Regional Office Director develop and implement a plan to ensure staff address all required elements of Systematic Analyses of Operations using thorough analysis.
Closure Date:
6 We recommend the Anchorage VA Regional Office Director develop and implement a plan to monitor the effectiveness of training to ensure staff follow current Veterans Benefits Administration policy regarding Gulf War Veterans' entitlement to mental health treatment when denying service connection for mental disorders.
Closure Date:
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| 11-01827-36 | Audit of VHA's Physician Staffing Levels for Specialty Care Services | Audit | ||
1 The Office of Inspector General recommends that the Under Secretary for Health approve a plan by the end of FY 2013 that ensures all specialty care services have productivity standards within 3 years.
Closure Date:
2 The Office of Inspector General recommends that the Under Secretary for Health establish productivity standards for at least five specialty care services by the end of FY 2013 and ensure medical facility personnel compare physician workload against these standards.
Closure Date:
3 The Office of Inspector General recommends that the Under Secretary for Health provide medical facility directors with more specific guidance on how to develop staffing plans and ensure medical facility management review them at least annually to ensure optimal efficiency.
Closure Date:
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| 12-03543-73 | Healthcare Inspection – Alleged Patient Safety Deficiencies in the Community Living Center, Canandaigua VA Medical Center, Canandaigua, New York | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director implement procedures to ensure that unit-level reviews of patient falls are patient-specific and address the specific circumstances surrounding the falls.
Closure Date:
2 We recommended that the facility Director implement procedures to ensure that fall prevention interventions are documented in patient care plans.
Closure Date:
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| 12-02352-72 | Healthcare Inspection – Pharmacy and Quality of Care Issues, VA Hudson Valley Health Care System, Castle Point, New York | Hotline Healthcare Inspection | ||
1 We recommended that the Director ensure that the recommendations included in the Administrative Investigation Board report are complied with.
Closure Date:
2 We recommended that the Director ensure that all pharmacy staff be provided ethics training to ensure that employees report unethical behavior without fear of repercussion.
Closure Date:
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14917