Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
Closure Date:
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.
Closure Date:
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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.
Closure Date:
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).
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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| 22-04132-48 | Comprehensive Healthcare Inspection of the Tomah VA Medical Center in Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by conducting Ongoing Professional Practice Evaluations on a regular basis.
Closure Date:
2 The Medical Center Director ensures the Safety and Occupational Health Specialist or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.
Closure Date:
3 The Medical Center Director ensures staff monitor and document VA police response times to panic alarm testing in the Acute Inpatient Mental Health Unit at least quarterly.
Closure Date:
4 The Medical Center Director ensures the Suicide Prevention Coordinator conducts a minimum of five outreach activities each month.
Closure Date:
5 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health and quality management leaders.
Closure Date:
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| 23-00093-51 | Comprehensive Healthcare Inspection of the Wilmington VA Medical Center in Delaware | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff track deficiencies identified during comprehensive environment of care inspections through resolution.
Closure Date:
2 The Director ensures staff maintain a safe and clean environment.
Closure Date:
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| 21-01488-44 | Veterans Health Administration Needs More Written Guidance to Better Manage Inpatient Management of Alcohol Withdrawal | National Healthcare Review | ||
1 The Under Secretary for Health consider identifying a national program office to be responsible for oversight of alcohol withdrawal management across inpatient settings.
Closure Date:
2 The Under Secretary for Health ensures the identified national program office responsible for oversight of alcohol withdrawal management consider requiring the development and implementation of written guidance for the management of alcohol withdrawal across all inpatient settings, to include: (a) expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; (b) expected actions of nurses to communicate with prescribers based on patients’ changes in symptoms or alcohol withdrawal severity and when that communication should be followed by a prescribers face-to-face evaluation of a patient; (c) expectations for the evaluation of co-occurring conditions, expert consultation, and pharmacotherapy approaches; and (d) expectations for the collection and monitoring of outcome data for inpatient management of alcohol withdrawal at the national and healthcare system level.
Closure Date:
3 The Under Secretary for Health consider the implementation of training for inpatient staff on the administration of standardized alcohol withdrawal severity scales.
Closure Date:
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| 22-02294-42 | Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates a review of the surgeon’s eligibility to participate in VA’s Community Care Network given Optum’s lack of documentation of their review of the surgeon’s credentialing file and takes action, as indicated.
Closure Date:
2 The Under Secretary for Health reviews community care network contracts and considers modifying contracts to ensure that voluntary relinquishments and surrenders of licenses for disciplinary reasons are disqualifying for participation in VA’s Community Care Network consistent with the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.
Closure Date:
3 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures Optum’s sufficient review and discussion of community care network providers’adverse credentialing files and monitors for compliance.
Closure Date:
4 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum documents community care network provider credentialing decisions asrequired and monitors for compliance.
Closure Date:
5 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum complies with community care contract provisions to provide Integrated Veteran Care with accreditation and credentialing documentation in accordance with federal privacy laws and VA’s community care network contract.
Closure Date:
6 The Office of Integrated Veteran Care Executive Director, Integrated External Networks verifies that providers identified on the 2021 Government Accountability Office list are eligible to provide care in the VA Community Care Network.
Closure Date:
7 The VA Heartland Network Director initiates a review of all community care provided by the surgeon.
Closure Date:
8 The VA Marion Health Care System Director ensures primary care and patient safety staff receive education on their responsibility for Joint Patient Safety Reporting and follow-up of patient safety events related to community care, and monitors compliance with patient safety event reporting and follow-up.
Closure Date:
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15770