Recommendations
2128
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00073-223 | Comprehensive Healthcare Inspection of the Alexandria VA Health Care System in Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs complete Focused Professional Practice Evaluations.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consistently review Ongoing Professional Practice Evaluation data.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen and include an assessment of whether the current suicidal ideation was the most severe in the last 30 days.
Closure Date:
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| 22-00074-218 | Comprehensive Healthcare Inspection of the Gulf Coast Veterans Health Care System in Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures leaders follow their defined governance structure.
Closure Date:
2 The Chief of Staff determines any additional reasons for noncompliance and ensures leaders use service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff determines any additional reasons for noncompliance and ensures service chiefs maintain Ongoing Professional Practice Evaluation data in licensed independent practitioners’ privileging folders.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff reviews the service chiefs’ recommendations along with clinical competence information when making privileging recommendations for licensed independent practitioners.
Closure Date:
6 The System Director determines any additional reasons for noncompliance and ensures staff maintain a clean and safe environment.
Closure Date:
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| 22-00076-222 | Comprehensive Healthcare Inspection of the Central Arkansas Veterans Healthcare System in Little Rock | Comprehensive Healthcare Inspection Program | ||
1 The Director determines the 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 evaluates and determines any additional reasons for noncompliance and ensures service chiefs define time frames for Focused Professional Practice Evaluations.
Closure Date:
3 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen for patients seen in the Emergency Department.
Closure Date:
4 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians create or update a suicide safety plan for patients determined to be at intermediate, high-acute, or chronic risk-for-suicide and safe to discharge home from the Emergency Department.
Closure Date:
5 The Director evaluates and determines any additional reasons for noncompliance and ensures clinicians follow up within seven days with patients determined to be at intermediate, high-acute, or chronic risk-for-suicide who were discharged home from the Emergency Department.
Closure Date:
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| 22-02800-225 | Delay in Diagnosis and Treatment for a Patient with a New Lung Mass at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director assesses the current use of care coordination agreements between the Patient Aligned Care Team and specialty care services, and determines if there would be benefit in developing agreements where they do not currently exist.
Closure Date:
2 The Hampton VA Medical Center Director, in conjunction with the Radiology Department chief, reviews the Radiology Department standard operating procedures and scheduling processes, identifies deficiencies, and ensures compliance with Veterans Health Administration policies.
Closure Date:
3 The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team processes, identifies deficiencies, and ensures compliance with Veterans Health Administration Patient Aligned Care Team requirements, including scheduling huddles, follow-up of Emergency Department patient discharges, and communication with and coordination of specialty care.
Closure Date:
4 The Hampton VA Medical Center Director, in conjunction with the Primary Care Service chief, reviews the Patient Aligned Care Team pain management and referral processes, identifies deficiencies, and takes action as warranted.
Closure Date:
5 The Hampton VA Medical Center Director, in consultation with a subject matter expert from the National Program Office for Oncology, reviews the facility cancer registry program, identifies deficiencies, and ensures compliance with Veterans Health Administration requirements, including the need for a qualified cancer registrar and entry of all cancer cases in the registry.
Closure Date:
6 The Hampton VA Medical Center Director reviews the completed root cause analysis in order to ensure its completeness, and take action if warranted.
Closure Date:
7 The Hampton VA Medical Center Director reviews the institutional disclosure made to the patient’s family and completes any required items not addressed, including providing the patient’s family with information about potential compensation from the Veterans Benefits Administration and under the Federal Tort Claims Act.
Closure Date:
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| 22-02377-217 | Review of Veterans Health Administration’s Multi-Tiered Patient Safety Program | National Healthcare Review | ||
1 The Assistant Under Secretary for Health for Quality and Patient Safety establishes facility patient safety program oversight requirements for patient safety officers to include minimum frequency and volume of oversight activities and expectations for follow-up when patient safety program deficiencies are identified.
Closure Date:
2 The National Center for Patient Safety Executive Director evaluates the National Center for Patient Safety quarterly reports, includes an analysis of patient safety data in the reports, and establishes a mechanism for National Center for Patient Safety, in conjunction with Veteran Integrated Service Networks, to direct interventions to promote improvements when facility patient safety program requirements are not met or if deemed necessary to enhance patient safety programs.
Closure Date:
3 The Under Secretary for Health evaluates barriers to communication between third-party administrators and patient safety officers and takes action as needed to resolve barriers.
Closure Date:
4 The Assistant Under Secretary for Health for Quality and Patient Safety evaluates barriers that limit engagement between Veteran Integrated Service Network and facility directors and patient safety officers and patient safety managers.
Closure Date:
5 The National Center for Patient Safety Executive Director develops a patient safety program staffing configuration for patient safety managers to include facility complexity and patient safety program requirements with recurring reassessment and revision based on requirement changes.
Closure Date:
6 The National Center for Patient Safety Executive Director establishes staffing guidance for Veteran Integrated Service Network patient safety programs to include facility complexity and workload from other assigned responsibilities to ensure prioritization of patient safety officer oversight and support of facility patient safety programs.
Closure Date:
7 The National Center for Patient Safety Executive Director establishes processes to evaluate factors contributing to patient safety managers and patient safety officers’ burnout, including patient safety manager turnover, and implements actions as needed to address burnout.
Closure Date:
8 The National Center for Patient Safety Executive Director evaluates patient safety manager and patient safety officer training and implements standardized formalized training with requirements for newly appointed patient safety managers and newly appointed patient safety officers to include time frames and completion.
Closure Date:
9 The National Center for Patient Safety Executive Director establishes standardized continuing education requirements to meet the training needs for patient safety managers and patient safety officers.
Closure Date:
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| 23-01138-203 | Inspection of Information Security at the VA Dublin Healthcare System in Georgia | Information Security Inspection | ||
1 Improve vulnerability management processes to ensure system changes occur within organization timelines.
Closure Date:
2 Develop and approve an authorization to operate for the special-purpose systems.
Closure Date:
3 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:
4 Review the list of unauthorized software and remediate or remove unneeded software at the facility.
Closure Date:
5 Implement the appropriate physical security controls to restrict and monitor access to the facility, its server room, communication closets, and generators.
6 Implement and monitor emergency power and uninterruptible power supplies that support information technology resources.
Closure Date:
7 Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
Closure Date:
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| 23-01179-204 | Inspection of Information Security at the VA El Paso Healthcare System in Texas | Information Security Inspection | ||
1 Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.
Closure Date:
2 Ensure vulnerabilities are remediated within OIT’s established time frames.
3 Ensure that physical access for the data center and communication rooms are reviewed on a quarterly basis.
Closure Date:
4 Ensure physical access controls are implemented for communication rooms.
Closure Date:
5 Ensure a video surveillance system is operational and monitored for the data center.
6 Ensure communication rooms with infrastructure equipment have adequate environmental controls.
Closure Date:
7 Ensure water detection sensors are implemented in the data center.
8 Test the emergency power bypass during annual uninterruptible power supply testing and document results.
Closure Date:
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| 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:
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| 22-03525-195 | VA Should Strengthen Enterprise Cloud Security and Privacy Controls | Audit | ||
1 The assistant secretary for information technology develop a timeline for updating the security and privacy guidance to reflect the latest revisions to the National Institute of Standards and Technology Special Publication 800-53, Security and Privacy Controls for Federal Information Systems and Organizations, and address identified weaknesses with personally identifiable information and supply chain management.
Closure Date:
2 The assistant secretary for information technology eEstablish a mechanism to ensure continuous monitoring of VA Enterprise Cloud systems to include having and testing contingency, incident response, and disaster recovery plans and conducting scanning as required.
Closure Date:
3 The assistant secretary for information and technology ensure VA Directive and Handbook 6517 are updated to reflect the revised National Institute of Standards and Technology requirements.
4 The assistant secretary for information and technology continue to improve criteria and processes for submitting claims for recoupment of service credits.
Closure Date:
5 The assistant secretary for information and technology assign roles and responsibilities for submitting claims for service credits and monitoring outcomes.
Closure Date:
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| 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:
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15333