Recommendations
2057
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-00018-83 | Comprehensive Healthcare Inspection of the Minneapolis VA Health Care System in Minnesota | 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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| 23-00017-81 | Comprehensive Healthcare Inspection of the Alaska VA Healthcare System in Anchorage | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures Supply Chain Management, Engineering, or Facility Management Service staff monitor temperature and humidity in all clean and sterile storage rooms to maintain a stable environment.
Closure Date:
2 The Executive Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to quality management staff.
Closure Date:
3 The Executive Director ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00010-84 | Comprehensive Healthcare Inspection of the James A. Haley Veterans’ Hospital in Tampa, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures staff keep areas used by patients clean and orderly.
Closure Date:
2 The Associate Director ensures staff store clean and dirty equipment and supplies separately.
Closure Date:
3 The Associate Director ensures staff place all examination tables with the foot facing away from the door.
Closure Date:
4 The Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
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| 23-00153-41 | Rating Schedule Updates for Hip and Knee Replacement Benefits Were Not Consistently Applied | Review | ||
1 Conduct a review of the convalescence claims for hip and knee replacements and resurfacing completed from February 7, 2021, through August 31, 2022, and take appropriate actions to correct convalescence periods and ensure monetary benefits are accurate.
2 Implement a plan to assist employees with determining the effective date, incorporating the initial month under 38 C.F.R. § 4.30, and calculating the duration of convalescence.
Closure Date:
3 Develop implementation procedures to include monitoring the accuracy of claims processing when the related rating schedule has been revised.
Closure Date:
4 Supplement training on the rating schedule updates to include how to apply the changes to help ensure comprehension.
Closure Date:
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| 22-04038-82 | Comprehensive Healthcare Inspection of the Battle Creek VA Medical Center in Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
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| 22-02113-75 | Care Concerns and Failure to Coordinate Community Care for a Patient at the VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The North Las Vegas VA Medical Center Director reviews the community care coordination program, identifies deficiencies, and takes actions as warranted to ensure compliance with the Veterans Health Administration Field Guidebook, including training and completion of all care coordination responsibilities for patients discharged from a community hospital stay paid for by the VA.
Closure Date:
2 The North Las Vegas VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the primary care processes, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including response time to patients’ scheduling requests and availability of same-day access for face-to-face and telephone encounters.
Closure Date:
3 The Sierra Pacific Network Director in conjunction with the Chief Medical Officer continues the review of the complete course of care provided by the Veterans Integrated Service Network physician for the patient, including the delivery of anticoagulants, and ability to access scanned documents in the electronic health record, and takes actions as warranted.
Closure Date:
4 The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief and the Primary Care Service chief, review the suicide prevention training program to ensure compliance with Veterans Health Administration policies, including reporting requirements following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.
Closure Date:
5 The North Las Vegas VA Medical Center Director, in conjunction with the Behavioral Health Service chief, reviews the suicide prevention coordinators’ compliance with Veterans Health Administration policies, including actions required to complete a behavioral health autopsy and family interview tool contact form following a patient’s death by suicide; identifies deficiencies; and takes actions as warranted.
Closure Date:
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| 23-01198-47 | Financial Efficiency Inspection of the VA Memphis Healthcare System in Tennessee | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of all VA financial policy requirements in the review and management of inactive open obligations and deobligate any identified excess funds.
Closure Date:
2 Ensure cardholders comply with VA financial policy record retention requirements.
Closure Date:
3 Establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.
Closure Date:
4 Establish local processes and procedures to ensure the routine scanning of inventory items, as well as monitoring of all inventory data, so that performance measures are maintained.
Closure Date:
5 Ensure supply chain managers implement a plan to train staff to promote the standardization of supply chain duties and to correct data validity issues within inventory systems.
Closure Date:
6 Ensure the chief of supply chain services conducts and documents quarterly physical inventory memoranda of “A” classified items in accordance with Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
7 Ensure the chief supply chain officer reviews the edit access list for the facility item master file, and a process is put in place to document this review, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
Closure Date:
8 Develop a plan to align inventory management practices, such as ABC inventory analysis methodology, with Veterans Health Administration policy.
Closure Date:
9 Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.
Closure Date:
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| 23-00011-73 | Comprehensive Healthcare Inspection of the Samuel S. Stratton VA Medical Center in Albany, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations.
Closure Date:
3 The Executive Medical Center Director ensures the Comprehensive Environment of Care Coordinator schedules, and staff complete and document, environment of care inspections at the required frequency.
Closure Date:
4 The Executive Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.
Closure Date:
5 The Executive Medical Center Director ensures appropriate personnel install over-the-door alarms for sleeping room doors in the mental health inpatient unit.
Closure Date:
6 The Executive Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on sleeping room doors in the mental health inpatient unit.
Closure Date:
7 The Executive Medical Center Director ensures staff maintain a safe environment in the mental health inpatient unit.
Closure Date:
8 The Executive Medical Center Director ensures staff keep patient care areas safe and clean.
Closure Date:
9 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.
Closure Date:
10 The Chief of Staff ensures the Suicide Prevention Coordinator conducts, tracks, and reports a minimum of five suicide prevention outreach activities monthly.
Closure Date:
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| 21-03255-02 | Noncompliance with Contractor Employee Vetting Requirements Exposes VA to Risk | Audit | ||
1 Mediate the two offices’ collaboration to develop and publish updates to the personnel security policies and procedures for vetting contractor employees to include appropriate roles and responsibilities; standard contract language to communicate the requirements for vetting contractor employees, including whether a fingerprint check or background investigation is required, that can be used across the department; and a requirement that the VA organization requesting a contract provide the position designation record in the acquisition package submitted to the contracting office.
2 Perform and document compliance inspections of the procedures for vetting contractor employees and the issuance of VA identification credentials at medical facilities supported by Network Contracting Office 23, including the St. Cloud VA Medical Center.
Closure Date:
3 Update and publish the Veterans Affairs Acquisition Regulation and Veterans Affairs Acquisition Manual to direct the department’s acquisition professionals to the correct guidance for vetting contractor employees, which should include VA’s personnel security and suitability program policy.
4 Update and publish or rescind Acquisition Policy Flash 16-13, “Use of VA Handbook 6500.6, Appendix A, Checklist for Information Security in VA Service Acquisitions,” to ensure VA acquisition professionals understand that VA Handbook 6500.6 is not the only personnel security policy they must comply with.
Closure Date:
5 Update and publish VA Handbook 6500.6, Contract Security, in collaboration with the Office of Acquisition, Logistics, and Construction and the Office of Human Resources and Administration/Operations, Security, and Preparedness, including retitling it to better correspond to its content and removing any personnel security steps that should only be discussed in VA personnel security and suitability program policies.
6 Review the actions of the officials responsible for planning, awarding, and administering contract 36C26320A0021, which included vetting procedures that did not comply with federal or VA policies, and take administrative action if appropriate.
Closure Date:
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| 22-04134-63 | Comprehensive Healthcare Inspection of the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff keep all areas clean and safe.
Closure Date:
2 The Director ensures staff keep the medical center well maintained.
Closure Date:
3 The Chief of Pharmacy Services limits medication access to approved staff members.
Closure Date:
4 The Director ensures staff store sterile supplies in temperature- and humidity-controlled storage rooms.
Closure Date:
5 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.
Closure Date:
6 The Director ensures providers notify the suicide prevention team of patients who report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
Closure Date:
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14922