Recommendations
2060
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00063-220 | Comprehensive Healthcare Inspection of the VA Northern California Health Care System in Mather | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs document professional practice evaluation results in practitioners’ profiles and report them to the Executive Committee of the Medical Staff Credentialing and Privileging.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures services chiefs base reprivileging recommendations on service-specific Ongoing Professional Practice Evaluation data.
Closure Date:
3 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff document VA Police response times to panic alarm testing in the inpatient mental health unit.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff keep patient care areas clean and maintain furnishings and equipment in good working order.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff test over-the-door alarms for inpatient mental health unit sleeping rooms as required.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff properly store and secure medications.
Closure Date:
7 The System Director evaluates and determines additional reasons for noncompliance and ensures staff conduct timely follow-up for intermediate, high-acute, or chronic risk-for-suicide patients who are discharged home from the Emergency Department.
Closure Date:
| ||||
| 22-00414-113 | Oversight Could Be Strengthened for Non-VA Healthcare Providers Who Prescribe Opioids to Veterans | Audit | ||
1 Clarify roles and responsibilities of the Office of Integrated Veteran Care and third-party administrators with respect to ensuring non-VA providers receive and certify they have reviewed Opioid Safety Initiative guidelines in accordance with the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 and collaborate with the contracting office to modify the contracts as appropriate.
Closure Date:
2 Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of the VA Opioid Safety Initiative training module.
3 Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of required prescription drug monitoring program queries
Closure Date:
| ||||
| 22-00071-216 | Comprehensive Healthcare Inspection of the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures staff complete an individual root cause analysis for all patient safety events assigned an actual or potential safety assessment code score of 3.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluation data.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs report Focused Professional Practice Evaluation results to the Medical Executive Board.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board reviews Ongoing Professional Practice Evaluation results and documents its review when making reprivileging recommendations to the Director.
Closure Date:
6 The Director determines the reasons for noncompliance and ensures staff conduct environment of care inspections at the required frequency.
Closure Date:
7 The Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.
Closure Date:
8 The Director determines any additional reasons for noncompliance and ensures staff maintain a safe environment in the inpatient mental health unit.
Closure Date:
9 The Associate Director for Patient/Nursing Services determines the reasons for noncompliance and ensures only authorized personnel have access to medication and supply rooms.
Closure Date:
| ||||
| 22-02017-224 | Review of VHA’s Oversight of Community Care Providers’ Opioid Prescribing at the Eastern Kansas Health Care System in Topeka and Leavenworth | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health collaborates with the region 2 third-party administrator to ensure that community care providers submit documentation of care to the Veterans Health
Administration including treatments provided specific to opioid risk mitigation (urine drug screening, prescription drug monitoring program checks) and all prescriptions, to include urgently/emergently prescribed opioids and utine/maintenance opioid prescriptions.
2 The VA Eastern Kansas Health Care System Director ensures system providers document evidence of Opioid Safety Initiative risk-mitigation strategies for patients who are on long-term opioids, as required by Veterans Health Administration policy.
Closure Date:
3 The Under Secretary for Health develops and implements action requiring community care network providers to document evidence of application of Opioid Safety Initiative risk mitigation strategies when treating a veteran to whom they have rescribed opioids, and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.
Closure Date:
4 The Under Secretary for Health develops and implements action requiring community care network providers to conduct and document completion of state prescription drug monitoring
program queries consistent with VHA policy, prior to prescribing controlled substances, regardless of whether the prescriptions are urgent, emergent, routine or maintenance prescriptions and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.
5 The Under Secretary for Health considers issuing formal guidance to all Veterans Health Administration pharmacy staff regarding best practices for conducting state prescription drug monitoring program queries upon receipt of controlled substance prescriptions from community care network providers.
Closure Date:
6 The Under Secretary for Health develops and implements a process to oversee compliance of VHA’s medication reconciliation process for patients receiving care in the community who are prescribed opioids to include recording of the prescriptions in the non-VA medication section of the medication profile.
Closure Date:
7 The Under Secretary for Health considers options and implements a process for including non VA medications prescribed by community care providers in the data populating the opioid safety tools.
Closure Date:
8 The VA Eastern Kansas Health Care System Director ensures that medications known to system staff are entered into the patient’s medication profile in the electronic health record.
Closure Date:
9 The VA Heartland Network Director ensures the Veterans Integrated Service Network Community Care Oversight Council conducts oversight of community care network providers’ opioid prescribing practices and reports results through the Opioid Prescribing Community Providers’ SharePoint site.
Closure Date:
10 The VA Heartland Network Director confirms that the VA Eastern Kansas Health Care System has a local process outlining expectations, roles, and responsibilities for completing reviews of community care network provider’s opioid prescribing practices and that the process is shared with system staff, initiated, and monitored.
Closure Date:
11 The VA Eastern Kansas Health Care System Director continues efforts to recruit and hire staff to fill vacant pain management positions.
Closure Date:
12 The Under Secretary for Health consults with the Office for Integrated Veteran Care to determine the value of including a review of community care network provider documentation for evidence of prescription drug monitoring program queries as a required element in VA’s Guidance for Community Provider Opioid Prescribing Practices Review.
Closure Date:
13 The VA Eastern Kansas Health Care System Director ensures system staff and leaders are educated on the processes to report patient safety concerns involving community care network providers.
Closure Date:
| ||||
| 22-02936-175 | Improvements Needed for VBA’s Claims Automation Project | Review | ||
1 Implement technology improvements and demonstrate progress to ensure the accuracy and completeness of information on the hypertension summary sheet.
2 Implement a process to communicate any change in policy, procedure, or the claims processing manual associated with all automated diagnostic codes between the Office of Automated Benefits Delivery, the Office of Policy and Oversight, the Office of Field Operations, and Compensation Service to ensure guidance is clear and consistent for all claims processors.
Closure Date:
3 Implement an improved quality assurance process and monitor the results to ensure the accuracy of hypertension summary sheets and final decisions.
4 Create or amend metrics to compare the timeliness of claims processing using automation tools versus the traditional process.
| ||||
| 22-00879-196 | VA’s Compliance with the VA Transparency & Trust Act of 2021 Semiannual Report: September 2023 | Review | ||
1 Ensure that Veterans Health Administration fiscal staff are trained on VA financial policy requirements for the preparation and approval of journal vouchers (including expenditure transfers).
Closure Date:
| ||||
| 22-00238-213 | Comprehensive Healthcare Inspection of the Michael E. DeBakey VA Medical Center in Houston, Texas | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures leaders conduct institutional disclosures for applicable sentinel events.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings and equipment safe and in good repair.
Closure Date:
| ||||
| 23-01177-215 | Comprehensive Healthcare Inspection Program Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensure providers counsel patients who have the potential to become pregnant on the risks and benefits of teratogenic medications prior to prescribing them and document this counseling in the electronic health record.
| ||||
| 23-00089-144 | Information Security Inspection at the VA Beckley Healthcare System in West Virginia | Information Security Inspection | ||
1 The assistant secretary for information and technology and chief information officer implement a process to minimize the Information Central Analytics and Metrics Platform data reliability issues.
Closure Date:
2 The assistant secretary for information and technology and chief information officer improve vulnerability management processes to ensure system changes occur within organization timelines.
3 The assistant secretary for information and technology and chief information officer develop and approve an authorization to operate for the special-purpose system.
Closure Date:
4 The assistant secretary for information and technology and chief information officer include system personnel during the security categorization process to ensure that all necessary information types are considered when determining the security categorization for special-purpose systems.
Closure Date:
5 The assistant secretary for information and technology and chief information officer implement improved mechanisms to ensure system stewards are creating plans of action and milestones for all controls that have not been implemented or assessed.
Closure Date:
6 The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with special-purpose systems.
Closure Date:
7 The VA medical center director install uninterruptible power supplies to eliminate single points of electrical failure supporting the facility.
Closure Date:
8 The VA medical center director ensure that hot and cold aisles in computer rooms, and electric and data cables are installed in accordance with VA standards.
9 The VA medical center director validate that appropriate physical and environmental security measures are implemented and functioning as intended.
10 The VA medical center director implement media sanitization methods in accordance with VA policy requirements.
Closure Date:
| ||||
| 21-03718-189 | VA’s Governance of its Personnel Suitability Program for Medical Facilities Continues to Need Improvement | Audit | ||
1 Establish robust oversight of the personnel suitability program within responsible office(s) that includes verifying background investigations are initiated and adjudicated within prescribed timelines and that documentation is filed as required.
Closure Date:
2 Reimplement the monitoring program specifically required by VA Handbook 0710 as part of VA’s oversight efforts, or an appropriate equivalent, to identify and prevent systemic weaknesses in the personnel suitability program.
Closure Date:
3 Assess program resources and allocate staff as needed to prioritize oversight of the personnel suitability program within responsible office(s).
Closure Date:
4 Establish a plan to implement the updated staffing metrics for the Veterans Health Administration’s suitability function and consider using available hiring flexibilities.
Closure Date:
5 Incorporate formal data-testing procedures (and data-matching as appropriate) of HR Smart and the VA Centralized Adjudication Background Investigation System (or any replacement systems) into the monitoring program discussed in recommendation 2.
Closure Date:
6 Develop and execute a plan to collect, maintain, and access sufficient and appropriate data through a single system to support the tracking of background investigations from initiation to adjudication.
Closure Date:
7 Establish a plan to ensure that future systems support the functionality needed to effectively oversee and manage the background investigation process, including addressing limitations identified in the current systems and incorporating the fields necessary to track timeliness metrics.
Closure Date:
| ||||
14935