Recommendations
2059
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
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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.
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2 The Director ensures staff keep the medical center well maintained.
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3 The Chief of Pharmacy Services limits medication access to approved staff members.
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4 The Director ensures staff store sterile supplies in temperature- and humidity-controlled storage rooms.
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5 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.
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6 The Director ensures providers notify the suicide prevention team of patients who report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
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| 23-00005-62 | Comprehensive Healthcare Inspection of the Ralph H. Johnson VA Medical Center in Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff complete root cause analyses for all patient safety events assigned an actual or potential safety assessment code score of 3.
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2 The Veterans Integrated Service Network Director ensures external practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for practitioners in “two-deep” services or specialties.
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3 The Medical Center Director ensures the Safety and Occupational Health Specialist or designee tracks environment of care inspection deficiencies until they are resolved.
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4 The Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit at least quarterly.
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5 The Medical Center Director ensures the Supervisory Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.
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| 22-02975-70 | Chief of Staff’s Provision of Care Without Privileges, Quality of Care Deficiencies, and Leaders’ Failures at the Montana VA Health Care System in Helena | Hotline Healthcare Inspection | ||
1 The Montana VA Health Care System Medical Center Director ensures that all providers, including the Chief of Staff, practice within their approved privileges.
Closure Date:
2 The Under Secretary for Health ensures review of Veterans Health Administration maternity care directives to determine if more specific guidance on the limitations of pregnancy care at VA facilities is necessary to ensure that pregnant patients receive maternity care according to evidence-based practice standards, and ensures guidance is updated as warranted.
Closure Date:
3 The Montana VA Health Care System Medical Center Director ensures adherence to Veterans Health Administration and facility policies for pregnancy care.
Closure Date:
4 The Montana VA Health Care System Medical Center Director ensures subject matter expert review of endometrial ablation procedures performed by the facility Chief of Staff to determine whether standards of care were followed for clinical indications, patient selection, and preoperative evaluation for patients who underwent endometrial ablation, and determine whether clinical disclosures or additional patient follow-up is indicated.
Closure Date:
5 The Rocky Mountain Network Director ensures processes are in place to support facilities’ external review process for ongoing professional practice evaluations in cases requiring external review by Veterans Health Administration policy and monitors compliance.
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6 The Montana VA Health Care System Medical Center Director ensures adherence to all VHA and facility policies pertaining to privileging and re-privileging of providers including the Chief of Staff.
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7 The Montana VA Health Care System Medical Center Director conducts a comprehensive review of the facility ongoing professional practice evaluation processes to ensure compliance with Veterans Health Administration and facility policy, and takes action as warranted.
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8 The Rocky Mountain Network Director ensures a process is in place to monitor for timely completion of administrative actions for members of facility executive leadership team when appropriate, identifies noncompliance, and takes action as warranted.
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9 The Rocky Mountain Network Director conducts a review of the state licensing board reporting processes at the facility to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.
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10 The Montana VA Health Care System Medical Center Director considers subject matter expert findings from the retrospective review of care provided by the Chief of Staff, determines whether clinical or institutional disclosures or additional patient follow-up is indicated, and takes action as warranted.
Closure Date:
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| 23-01325-59 | Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma | Hotline Healthcare Inspection | ||
1 The Oklahoma City VA Health Care System Director, in conjunction with Behavioral Health Service leaders, reviews the community care consult management and appointment scheduling processes, identifies deficiencies, and takes action as warranted.
Closure Date:
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| 23-00009-57 | Comprehensive Healthcare Inspection of the Columbia VA Health Care System in South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff have written procedures for responding to utility system disruptions.
Closure Date:
2 The Director ensures staff identify, minimize, or eliminate safety and security risks in the physical environment.
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3 The Director ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
4 The Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
Closure Date:
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| 22-00057-54 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 22: VA Desert Pacific Healthcare Network in Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 The Network Director determines the reasons for noncompliance and ensures the Patient Safety Officer collects, analyzes, and acts on peer review summary data.
Closure Date:
2 The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials file and makes a recommendation on continuing the appointment process for physicians with a potentially disqualifying licensure action.
Closure Date:
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| 22-04131-49 | Delay of a Patient’s Prostate Cancer Diagnosis, Failure to Ensure Quality Urologic Care, and Concerns with Lung Cancer Screening at the Central Texas Veterans Health Care System in Temple | Hotline Healthcare Inspection | ||
1 The Central Texas VA Health Care System Director reviews the care provided to the patient by Nurse Practitioner 1 and Nurse Practitioner 2 and takes action as warranted.
Closure Date:
2 The Central Texas VA Health Care System Director reviews the care provided by Nurse Practitioner 1 and Nurse Practitioner 2 as licensed independent practitioners to other urology patients, and takes action as warranted.
Closure Date:
3 The Central Texas VA Health Care System Director reviews the privileging and professional practice evaluation processes and performance indicators for nurse practitioners granted full practice authority in specialty care clinics to ensure compliance with current Veterans Health Administration policy and quality of care.
Closure Date:
4 The Central Texas VA Health Care System Director ensures that facility leaders communicate expectations related to low-dose computed tomography scans for lung cancer screening to facility primary care providers.
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| 22-03909-19 | VA Should Enhance Its Oversight to Improve the Accessibility of Websites and Information Technology Systems for Individuals with Disabilities | Audit | ||
1 Develop and implement a strategy with milestones for identifying all VA websites, confirm their inclusion in VA’s Web Registry as the current system designated by policy, and certify the accuracy of entries annually or as changes occur.
2 Establish a mechanism for web communication offices across VA to enforce the implementation of VA Handbook 6102 related to Section 508 compliance.
3 Coordinate with VA under secretaries and other assistant secretaries to ensure system owners are educated on VA Directive 6221 and its accompanying handbook requirements to request accessibility audits.
4 Institute a mechanism to ensure information technology system accessibility designations are accurate in the VA Systems Inventory.
Closure Date:
5 Update, recertify, and republish VA Directives 6221 (accessible information and communications technology) and 6404 (systems inventory).
6 Update, recertify, and publish VA Directive 6515 (use of web-based collaboration technologies).
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| 23-00777-52 | Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee | Hotline Healthcare Inspection | ||
1 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures Nursing Service staff comply with the cardiac telemetry monitoring policy.
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2 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures the medical floor charge nurses create nursing assignments and communicate this information to the telemetry technician and monitors for compliance.
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3 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that Intensive Care Unit Service physicians document and complete written responses to critical care consults as required and monitors for compliance.
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4 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that the Quality Management and Performance Improvement Service conduct administrative reviews and root cause analyses in accordance with Veterans Affairs and Veterans Health Administration policy and monitors for compliance.
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5 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director consider completion of another root cause analysis to ensure additional system vulnerabilities that may have contributed to this patient event are identified and action plans completed, as applicable, to prevent reoccurrence of similar patient events.
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14934