Recommendations
2055
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 12-03076-65 | Combined Assessment Program Review of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements and that providers re-evaluate patients immediately prior to sedation.
Closure Date:
2 We recommended that processes be strengthened to ensure that employees who perform glucose POCT have competency assessed at the required intervals.
Closure Date:
3 We recommended that the facility delineate all actions to be taken in response to critical results and that processes be strengthened to ensure that clinicians are notified of critical test results requiring follow-up.
Closure Date:
4 We recommended that processes be strengthened to ensure that staff complete the actions required in response to critical test results and document the actions taken and that compliance be monitored.
Closure Date:
5 We recommended that processes be strengthened to ensure that patients are notified of biopsy results within the required timeframe and that clinicians document notification.
Closure Date:
6 We recommended that processes be strengthened to ensure that patients with positive TBI screening results receive a comprehensive evaluation as outlined in VHA policy.
Closure Date:
7 We recommended that processes be strengthened to ensure that the EHR Committee provides consistent oversight and coordination of EHR quality reviews and that EHR quality reviews are analyzed and trended.
Closure Date:
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| 12-03346-69 | Review of VHA's Minor Construction Program | Audit | ||
1 We recommended the Under Secretary for Health publish policy for the Minor Construction Program.
Closure Date:
2 We recommended the Under Secretary for Health develop procedures to ensure minor construction projects are executed within their approved scope.
Closure Date:
3 We recommended the Under Secretary for Health review the seven minor construction projects that were integrated into three combined projects which exceeded the $10 million construction appropriation limit to determine if major construction projects were created, and take appropriate administrative action.
Closure Date:
4 We recommended the Under Secretary for Health implement a mechanism to ensure medical facility funding is not used to supplement minor construction projects.
Closure Date:
5 We recommended the Under Secretary for Health ensure internal program reviews of the Minor Construction Program are performed.
Closure Date:
6 We recommended the Under Secretary for Health strengthen minor construction Project Tracking Reports to ensure information is accurate and sufficient to monitor program performance.
Closure Date:
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| 10-01937-63 | Review of Allegations at VA Medical Center, Providence, Rhode Island | Audit | ||
1 We recommended the Veterans Integrated Service Network 1 Director establish controls to ensure the Providence VA Medical Center accurately certifies its Annual Certification of Accounting Records.
Closure Date:
2 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director terminates this contract, and if the services are still needed, recruits and hires under appropriate civil service procedures.
Closure Date:
3 We recommended the Veterans Integrated Service Network 1 Director require the Providence VA Medical Center Director to implement controls ensuring all fund obligations are accompanied by supporting documentation to justify the obligation as required by law.
Closure Date:
4 We recommended the Veterans Integrated Service Network 1 Director ensure service contracts are awarded based on adequate competition or, if competition is not feasible, are supported by limited or sole-source justifications as required by Federal Acquisition Regulation.
Closure Date:
5 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director establishes controls to ensure appropriated funds are used only for the intended purpose of the appropriation.
Closure Date:
6 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the Designated Education Officer to obtain and oversee annual rate changes for disbursing agreements.
Closure Date:
7 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director charges the Chief of Facilities Management Service 25 days of annual leave because his absence was not supported by an approved written justification.
Closure Date:
8 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director institutes a control that ensures at the point timecards are certified appropriate documentation in support of approved excused absences is in place.
Closure Date:
9 We recommended the Veterans Integrated Service Network 1 Director ensure the Providence VA Medical Center Director requires the property owner to make necessary repairs to alleviate future water leaks and damage, and if not repaired, moves employees in the affected areas to a more suitable workspace.
Closure Date:
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| 12-03741-61 | Combined Assessment Program Review of the VA Maine Healthcare System,Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are reported to the PRC.
Closure Date:
2 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed at least quarterly.
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 processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks and that oxygen tanks are not stored near electrical circuit breaker panels.
Closure Date:
5 We recommended that processes be strengthened to ensure that required preventive maintenance is performed on designated equipment in the physical therapy clinics.
Closure Date:
6 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
Closure Date:
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| 11-00317-37 | Audit of Vocational Rehabilitation and Employment Program's Self-Employment Services at Eastern and Central Area Offices | Audit | ||
1 We recommended the Under Secretary for Benefits implement procedures to improve the accuracy of data in Corporate WINRS.
Closure Date:
2 We recommended the Under Secretary for Benefits perform a data integrity review comparing Corporate WINRS to active self-employment Counseling/Evaluation/Rehabilitation files and take corrective action as needed.
Closure Date:
3 We recommended the Under Secretary for Benefits develop and implement performance measures that evaluate the success of self-employment services.
Closure Date:
4 We recommended the Under Secretary for Benefits provide training to Eastern and Central area Vocational Rehabilitation and Employment staff to ensure they understand the criteria used to determine rehabilitation status for participants in self-employment services.
Closure Date:
5 We recommended the Under Secretary for Benefits include guidance in Veterans Benefits Administration's Manual M28 to clarify when it is appropriate to provide services for veterans with an established business under a self-employment plan.
Closure Date:
6 We recommended the Under Secretary for Benefits revise Veterans Benefits Administration's Manual M28, Part IV, to ensure Veterans Benefits Administration's guidance aligns with Title 38, Code of Federal Regulations, for approval of self-employment plans.
Closure Date:
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| 12-03071-53 | Combined Assessment Program Review of the Fayetteville VA Medical Center, Fayetteville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect sufficient analysis and follow-up of EOC inspection findings and track identified deficiencies to resolution.
Closure Date:
2 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
Closure Date:
3 We recommended that processes be strengthened to ensure that the hazardous materials inventory is current.
Closure Date:
4 We recommended that processes be strengthened to ensure that hazard assessments are completed in the dental laboratory and the ED and that emergency eyewash stations are added if needed.
Closure Date:
5 We recommended that processes be strengthened to ensure that required SCI outpatient clinic staff are assigned and receive SCI-specific training and that compliance with training requirements be monitored.
Closure Date:
6 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:
7 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:
8 We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe and that the facility evaluate the five cases to determine what further actions may be warranted.
Closure Date:
9 We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
Closure Date:
10 We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers.
Closure Date:
11 We recommended that processes be strengthened to ensure that discharge summaries include discharge medications.
Closure Date:
12 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
Closure Date:
14 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
Closure Date:
15 We recommended that processes be strengthened to ensure that the designated clinical service respond to consultation requests for TBI comprehensive evaluations within the required timeframe.
Closure Date:
16 We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation within the required timeframe.
Closure Date:
17 We recommended that the facility comply with polytrauma training requirements.
Closure Date:
18 We recommended that senior managers discuss the data from the Inpatient Evaluation Center at a senior-level committee and document the discussion in the committee's meeting minutes.
Closure Date:
19 We recommended that processes be strengthened to ensure that FPPEs are completed for all newly hired licensed independent practitioners and that results are consistently reported to the Medical Executive Committee.
Closure Date:
20 We recommended that processes be strengthened to ensure that clinical service EHR quality reviews are completed and results forwarded to the EHR Committee and that the EHR Committee provides consistent oversight, coordination, and evaluation of EHR quality reviews.
Closure Date:
21 We recommended that processes be strengthened to ensure that the copy and paste functions are monitored.
Closure Date:
22 We recommended that processes be strengthened to ensure that staff complete all actions required in response to critical test results.
Closure Date:
23 We recommended that processes be strengthened to ensure that providers sign all pre-sedation assessments completed by nursing staff.
Closure Date:
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| 12-03073-57 | Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs are initiated for all newly hired licensed independent practitioners.
Closure Date:
2 We recommended that processes be strengthened to ensure that all completed ethics consultations are documented in ECWeb.
Closure Date:
3 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
4 We recommended that processes be strengthened to ensure that patients are appropriately monitored during moderate sedation
Closure Date:
5 We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
Closure Date:
6 We recommended that processes be strengthened to ensure that clinical staff in areas where moderate sedation is performed are aware of local policy requirements for identifying correct surgical and invasive procedure sites when the sites cannot be marked.
Closure Date:
7 We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers.
Closure Date:
8 We recommended that processes be strengthened to ensure that providers document care hand-off in accordance with local policy.
Closure Date:
9 We recommended that processes be strengthened to ensure that interdisciplinary teams develop treatment plans for all polytrauma outpatients who need them and that the plans contain all required elements.
Closure Date:
10 We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
Closure Date:
11 We recommended that processes be strengthened to ensure that service directors develop program-specific competencies and training for all staff assigned to the Polytrauma-TBI Program.
Closure Date:
12 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks.
Closure Date:
13 We recommended that processes be strengthened to ensure that SCI outpatient clinic employees receive population-specific training.
Closure Date:
14 We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
Closure Date:
15 We recommended that the facility implement the mandated staffing methodology for nursing personnel.
Closure Date:
16 We recommended that processes be strengthened to ensure that all POCT instruments are inspected by biomedical engineering prior to initial use.
Closure Date:
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| 12-03075-52 | Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC-Safety and IC Committee minutes reflect sufficient data analysis, actions implemented, and tracking of items to closure.
Closure Date:
2 We recommended that a comprehensive EOC inspection of the ED be conducted and that appropriate actions be taken to correct IC and safety deficiencies.
Closure Date:
3 We recommended that processes be strengthened to ensure that emergency exits are not obstructed.
Closure Date:
4 We recommended that processes be strengthened to ensure that MSDS inventory lists and hazardous materials information binders are current and that staff are trained on accessing the electronic MSDS materials.
Closure Date:
5 We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and SCI outpatient clinic.
Closure Date:
6 We recommended that processes be strengthened to ensure that medications, chemicals, solutions, and cleaning carts are properly secured.
Closure Date:
7 We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections and daily room inspections are conducted and that inspection reports contain adequate documentation of follow-up.
Closure Date:
8 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
Closure Date:
9 We recommended that processes be strengthened to ensure that all informed consents are completed appropriately and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
Closure Date:
10 We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo monthly urine drug screenings.
Closure Date:
11 We recommended that processes be strengthened to ensure that discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
Closure Date:
12 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated timely and documented and that compliance be monitored.
Closure Date:
13 We recommended that processes be strengthened to ensure that all patients are notified of biopsy results within the required timeframe and that clinicians document notification in the EHR.
Closure Date:
14 We recommended that processes be strengthened to ensure that clinician notification of critical test results is documented on the required template.
15 We recommended that local policies related to FSBG monitoring and patient management be updated to reflect actual practice.
Closure Date:
16 We recommended that processes be strengthened to ensure that all services complete EHR quality reviews.
Closure Date:
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| 12-03399-54 | Healthcare Inspection - Inpatient and Residential Programs for Female Veterans with Mental Health Conditions Related to Military Sexual Trauma | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health review existing VHA policy pertaining to authorization of travel for veterans seeking MST related MH treatment at specialized inpatient/residential programs outside of the facilities where they are enrolled.
Closure Date:
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| 12-03072-48 | Combined Assessment Program Review of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that at least two preventive ethics improvement cycles are completed each FY.
Closure Date:
2 We recommended that processes be strengthened to ensure that the EHR committee provides consistent oversight and coordination of EHR quality reviews and that quality reviews are completed, analyzed, and trended for all services, including long-term care.
Closure Date:
3 We recommended that a rehabilitation nurse be available for the polytrauma program.
Closure Date:
4 We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo urine drug screenings with the frequency required by local policy.
Closure Date:
5 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up evaluations at the required intervals and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that employees who perform glucose POCT have their competency assessed at the required intervals.
Closure Date:
8 We recommended that processes be strengthened to ensure that staff complete and document the actions required in response to critical test results.
Closure Date:
9 We recommended that processes be strengthened to ensure that Clinical Engineering staff inspect, approve, and label glucose meters in accordance with local policy.
Closure Date:
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14917