Recommendations
2062
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00031-67 | Deficiencies in the Patient Safety Program and Oversight Provided by Facility and VISN Leaders at the Tuscaloosa VA Medical Center in Alabama | Hotline Healthcare Inspection | ||
1 The Tuscaloosa VA Medical Center Director confirms that a process is in place to review all Joint Patient Safety Reporting event reports for completion within 14 days of submission and monitor progress.
Closure Date:
2 The Tuscaloosa VA Medical Center Director ensures event report investigation and feedback documentation has been fully completed in the Joint Patient Safety Reporting system.
Closure Date:
3 The Tuscaloosa VA Medical Center Director reviews the risk associated with the Joint Patient Safety Reporting event reports managed by the former Patient Safety Manager, including those that were rejected and those without completed investigations, to determine whether they warrant further review and if so, ensures the review is completed and actions required resulting from the review are completed.
Closure Date:
4 The Tuscaloosa VA Medical Center Director reviews the organizational structure and process for oversight of the eight annually required patient safety analyses to ensure they are completed and validated moving forward in accordance with Veterans Health Administration requirements.
Closure Date:
5 The Under Secretary for Health reviews the current process for providing access to the Joint Patient Safety Reporting system and WebSPOT to determine whether any specific staff positions would benefit from automatic access upon hire into the position.
Closure Date:
6 The Under Secretary for Health conducts an evaluation to determine whether Veterans Health Administration employees with active clinical licenses regardless of licensure requirement for their current position must report State Licensing Board actions against their clinical license to their supervisor.
Closure Date:
7 The Tuscaloosa VA Medical Center Director conducts a review of current fiscal year High Reliability Organization Committee and Executive Leadership Council meeting minutes to confirm that they reflect discussion, analysis, and needed follow-up of Patient Safety Program data for review and action.
Closure Date:
8 The Veterans Integrated Service Network Director reviews the JPSR Business Rules and Guidebook and determines which, if any, subset of patient safety event reports for each facility the Patient Safety Officer will review.
Closure Date:
9 The Veterans Integrated Service Network Director evaluates the role of the Patient Safety/ Risk Management Subcommittee to determine the degree to which the subcommittee will address facility level performance with Patient Safety Program activities and tracking of action plans when a deficiency is identified, and updates the subcommittee charter as warranted.
Closure Date:
10 The Under Secretary for Health ensures that policies related to patient safety are updated to reflect current required practice, publishes, and disseminates the updated policy (ies).
Closure Date:
11 The Under Secretary for Health evaluates the process for programmatic oversight by VA’s National Center for Patient Safety over Veterans Integrated Service Networks’ and facilities’ patient safety programs.
Closure Date:
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| 21-03718-47 | Personnel Suitability Process Concerns at the Beckley VA Medical Center in West Virginia | Review | ||
1 Conduct an all-personnel audit of Beckley VA Medical Center staff to ensure background investigation requirements were met, to include considering an all-personnel data match of relevant suitability records against comparable datasets from the Personnel Investigations Processing System, and report results to the Workforce Management and Consulting office for verification.
Closure Date:
2 Establish a project management plan to conduct compliance checks at other Veterans Integrated Service Network 5 facilities and share the plan with other networks.
Closure Date:
3 Evaluate staffing levels for the personnel suitability program and allocate staff as needed to meet VA timelines.
Closure Date:
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| 22-03770-49 | Security and Incident Preparedness at VA Medical Facilities | Review | ||
1 The Secretary of Veterans Affairs delegates to a responsible official the monitoring of VA facilities’ security-related vacancies and reports monthly on hiring trends and whether recent recruitment and hiring authorities established since the fiscal year 2021 Police National Strategic Recruitment Plan are resulting in improvements.
Closure Date:
2 The Secretary of Veterans Affairs authorizes sufficient staff for the Human Resources and Administration/Operations, Security and Preparedness’ Office of Security and Law Enforcement to inspect the VA police forces, per the OIG’s 2018 unimplemented recommendation.
Closure Date:
3 The under secretary for health ensures medical facility directors use appropriate measures to assess VA police staffing needs, authorizes associated positions, and leverages available mechanisms to fill vacancies.
Closure Date:
4 The under secretary for health verifies that medical facility directors commit sufficient resources to make certain that facility security measures are adequate, current, and operational.
Closure Date:
5 The under secretary for health directs Veterans Integrated Service Network police chiefs, in coordination with medical facility directors, facility police chiefs, and facility emergency management leaders, to present a plan to remedy identified security weaknesses, including inoperative cameras, unsecured doors, and the lack of security presence at main entrances.
Closure Date:
6 The assistant secretary for Human Resources and Administration/Operations, Security, and Preparedness establishes policy that standardizes the review and retention requirements for footage captured by facility security cameras.
Closure Date:
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| 21-03310-54 | Comprehensive Healthcare Inspection of the Memphis VA Medical Center in Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines any additional reasons for noncompliance and makes certain that service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs’ recommendations to continue licensed independent practitioners’ privileges are based, in part, on Ongoing Professional Practice Evaluation data.
Closure Date:
3 The Medical Center Director determines any additional reasons for noncompliance and makes certain the Comprehensive Environment of Care Coordinator or designee schedules and ensures completion of environment of care inspections in patient care areas at the required frequency or maintains documentation to support pandemic-related postponement.
Closure Date:
4 The Medical Center Director determines the reasons for noncompliance and ensures staff post signage in all areas where biohazards are present.
Closure Date:
5 The Medical Center Director determines the reasons for noncompliance and ensures the Chief of Police, Privacy Officer, and chiefs of programs identify medical center areas as a treatment, secure, personal, or other area.
Closure Date:
6 The Medical Center Director determines the reasons for noncompliance and ensures leaders comply with VHA requirements for signage and camera-recording, based on area designations.
Closure Date:
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| 22-01721-35 | Financial Efficiency Inspection of the Northern Arizona VA Health Care System | Financial Inspection | ||
1 Ensure that healthcare system finance office staff and initiating services are made aware of policy requirements to conduct reviews on all inactive open obligations and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 Ensure the healthcare system staff are conducting the accounting operations finance quality assurance review, including the review of undelivered orders, as required by Veterans Health Administration Directive 1733, VHA Finance Quality Assurance Reviews.
Closure Date:
3 Establish controls to confirm approving officials and purchase cardholders review their purchases and make sure contracting is used when it is in the best interest of the government.
Closure Date:
4 Review all invoices for continuous positive airway pressure machines for overcharges.
Closure Date:
5 Develop a control to ensure required supporting documentation is received from vendors that ship directly to veterans.
Closure Date:
6 Ensure all supplies are entered into the Generic Inventory Package as required by Veterans Health Administration policy.
Closure Date:
7 Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package per Veterans Health Administration policy.
Closure Date:
8 Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration–recommended level.
Closure Date:
9 Develop a plan to align inventory management practices, such as the use of handheld scanners, barcode labeling, and ABC inventory analysis methodology, with VHA policy.
Closure Date:
10 Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.
Closure Date:
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| 22-01565-29 | Financial Efficiency Inspection of the VA Palo Alto Health Care System in California | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of policy requirements and that reviews are conducted on all inactive open obligations, and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 Ensure cardholders comply with record retention requirements as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases,”
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 Require purchase cardholders to submit a request for ratification for any unauthorized commitments identified.
Closure Date:
5 Ensure purchase card reviews are performed as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases,”
Closure Date:
6 Ensure the chief of supply chain services establishes local processes and procedures so that all necessary reports are monitored on Supply Chain Common Operating Picture, the Generic Inventory Package, or other inventory sites or software systems, on a routine basis, as required in the Veterans Health Administration’s Directive 1761 Supply Chain Management Operations.
Closure Date:
7 Ensure supply chain management staff implement a plan for staff training to increase awareness of internal controls and data reliability within the Generic Inventory Package.
Closure Date:
8 Ensure the chief of supply chain services signs quarterly physical inventory memorandums of “A” classified items and make them available to Veterans Integrated Service Network personnel as required in the Veterans Health Administration’s Directive 1761 Supply Chain Management Operations.
Closure Date:
9 Develop and implement a plan to increase inventory turnover to meet the level recommended by the Veterans Health Administration Pharmacy Benefits Management Office.
Closure Date:
10 Develop and implement a plan to complete monthly B09 reconciliation consistently to ensure discrepancies are corrected in a timely manner.
Closure Date:
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| 22-01363-52 | Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California | Hotline Healthcare Inspection | ||
1 The VA Northern California Health Care System Director ensures mental health prescribing provider same-day access.
Closure Date:
2 The VA Northern California Health Care System Director makes certain that when a patient cannot engage in a risk assessment, the provider documents the reasons for the patient’s inability to complete the assessment, and risk and protective factors, as required by the Veterans Health Administration.
Closure Date:
3 The VA Northern California Health Care System Director ensures the nurse practitioner documents in patients’ electronic health records the comprehensive rationale for medication choices, schedules follow-up appointments consistent with clinical monitoring needs, and accurately documents medication instructions.
Closure Date:
4 The VA Northern California Health Care System Director conducts a full review of the patient’s care, determines if an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
5 The VA Northern California Health Care System Director expedites planned environmental changes to the Chico Community-Based Outpatient Mental Health Clinic.
Closure Date:
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| 21-02612-53 | Delayed Cancer Diagnosis and Deficiencies in Care Coordination for a Patient at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 The Overton Brooks VA Medical Center Director evaluates the processes for the communication of abnormal radiology imaging results and ensures patients receive timely notification, per Veterans Health Administration and facility requirements.
Closure Date:
2 The Overton Brooks VA Medical Center Director ensures oversee all clinical decisions and documentation made by residents and the oversight is reflected within the documentation.
Closure Date:
3 The Overton Brooks VA Medical Center Director reviews the processes for assigning a provider surrogate and monitors compliance.
Closure Date:
4 The Overton Brooks VA Medical Center Director ensures that concerns are entered into the Joint Patient Safety Reporting System and appropriate follow-up is completed.
Closure Date:
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| 21-01711-50 | Improvements Recommended in Visit Frequency and Contingency Planning for Emergencies in Intensive Community Mental Health Recovery Programs | National Healthcare Review | ||
1 The Under Secretary for Health ensures the Office of Mental Health and Suicide Prevention develops, implements, and monitors action plans to meet Intensive Community Mental Health Recovery visit frequency requirements, to include program resource needs and the ongoing role for virtual care.
2 The Under Secretary for Health requires the Office of Mental Health and Suicide Prevention to develop a process for Intensive Community Mental Health Recovery programs to ensure veterans receiving low-intensity services do not represent greater than 20 percent of caseloads and to distinguish between veterans receiving high- and low-intensity services for accurate and effective program oversight.
3 The Under Secretary for Health identifies barriers and ensures healthcare systems develop, implement, and maintain contingency plans specific to Intensive Community Mental Health Recovery programs regarding veteran access to medications during emergencies, including long-acting injectable antipsychotic medications.
Closure Date:
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| 21-03864-34 | Noncompliance with Community Care Referrals for Substance Abuse Residential Treatment at the VA North Texas Health Care System | Hotline Healthcare Inspection | ||
1 The VA North Texas Health Care System Director ensures that staff provide alternative treatment options, including community residential care referrals, when Veterans Health Administration admission wait time for substance abuse disorder residential rehabilitation treatment exceeds 30 days, and monitors compliance.
Closure Date:
2 The VA North Texas Health Care System Director conducts a comprehensive review of the management of community residential care referrals and takes action as warranted.
Closure Date:
3 The Under Secretary for Health ensures that Veterans Integrated Service Network leaders provide adequate oversight to ensure adherence to the mental health residential rehabilitation treatment program access to care policy as required.
Closure Date:
4 The VA North Texas Health Care System Director makes certain that the Bonham Substance Abuse Residential Rehabilitation Treatment Program procedures are consistent with Veterans Health Administration scheduling requirements, and monitors compliance.
Closure Date:
5 The Under Secretary for Health strengthens mental health treatment coordinator assignment procedures for patients awaiting mental health residential rehabilitation treatment program admission as warranted.
Closure Date:
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14943