Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-03772-28 | Care in the Community Summary Report for Fiscal Year 2022 | Care in the Community Healthcare Inspection | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff document veterans’ care coordination needs within the Community Care Coordination Plan note for consults assigned a level of care coordination above basic.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff act on consults no later than two business days after receipt and document accordingly.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff schedule community care appointments in a timely manner.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff make three attempts to retrieve medical documentation from non-VA providers.
Closure Date:
5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures patients in the home dialysis program receive initial and annual home visits.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures staff implement and sustain processes to monitor the delivery of non-VA home dialysis.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors, ensures each Veterans Integrated Service Network establishes a dialysis council.
Closure Date:
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| 21-02984-179 | Better Coordination Needed to Negotiate Consistent Prices for Prescription Eyeglasses | Review | ||
1 Coordinate with the executive director of the Prosthetic and Sensory Aids Service and officials from the Veterans Health Administration’s Procurement and Logistics Office and the VA Office of Acquisition, Logistics, and Construction to develop and implement a sourcing strategy, such as national contracts or a pricing catalog across all contracts by vendor for eyeglasses prescribed by a VA provider.
Closure Date:
2 Coordinate with the executive directors of the Prosthetic and Sensory Aids Service and the Veterans Health Administration’s Office of Procurement to implement a process to ensure contracting officers coordinate before awarding any Veterans Integrated Service Network–level contracts for eyeglasses to make sure these vendors offer the Veterans Health Administration the best pricing that is also consistent for the same or similar items to the extent possible.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $6,500,000
Total: $6,500,000
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| 22-00240-17 | Comprehensive Healthcare Inspection of the Overton Brooks VA Medical Center in Shreveport, 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 for all licensed independent practitioners.
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 licensed independent practitioners’ professional practice evaluations.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in licensed independent practitioners’ professional practice evaluations.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs consider relevant Ongoing Professional Practice Evaluation data in reprivileging recommendations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board uses professional practice evaluation results to recommend privileges for licensed independent practitioners.
Closure Date:
6 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct environment of care inspections in patient care areas at the required frequency.
Closure Date:
7 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures Automated External Defibrillator cabinets containing naloxone have alarms set in the “on” position, contain tamper-evident seals, display laminated “N” signs, and include naloxone inspection logs and administration reference cards.
Closure Date:
8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff check inventory in clean storerooms and remove expired supplies in the Emergency Department and medical/surgical inpatient unit.
Closure Date:
9 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Environmental Management Service maintains clean floors in the Dialysis Unit and medical/surgical inpatient unit clean storage and supply rooms.
Closure Date:
10 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff maintain safe and functional environments in the Dialysis Unit and medical/surgical inpatient unit.
Closure Date:
11 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff keep furnishings safe and in good repair in the intensive care and medical/surgical inpatient units.
Closure Date:
12 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff repair damaged walls in the Dental Clinic and Emergency Department.
Closure Date:
13 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures staff replace stained ceiling tiles in the Emergency Department and Primary Care Red Team.
Closure Date:
14 The Medical Center Director determines any additional reasons for noncompliance and ensures staff post signage where recording equipment is used in the intensive care and medical/surgical inpatient units, Dental Clinic, and Primary Care Red Team indicating the areas are subject to photography, digital imaging, video, or audio recording.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers assess whether patients’ most recent suicide attempt was their most lethal when completing the Comprehensive Suicide Risk Evaluation.
Closure Date:
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| 23-00383-21 | Delayed Receipt of Patients’ Colorectal Cancer Screening Tests at the Phoenix VA Health Care System in Arizona | Hotline Healthcare Inspection | ||
1 The Facility Director reviews the more than 400 fecal immunochemical test specimens received by the laboratory to determine whether the processes completed were compliant with laboratory standards and policies, and ensures future specimens are received, accessioned, and processed by approved personnel.
Closure Date:
2 The Veterans Integrated Service Network Director provides oversight of facility leaders’ thorough review of laboratory fecal immunochemical test processing practices to ensure laboratory staff confirm that fecal immunochemical test specimens include the date the patient collected the specimen, utilize the collection date to determine stability, and accurately record and process specimens with strict adherence to specimen stability standards and Veterans Health Administration and facility policies, and monitors compliance.
Closure Date:
3 The Facility Director establishes a multidisciplinary team (laboratory, primary care, gastroenterology, quality) to conduct a system-wide evaluation of the fecal immunochemical test processes and practices across departments, identify areas for improvement (such as staff training, patient education, and standardized protocols), and implement recommended changes, and monitors for compliance and sustainment.
Closure Date:
4 The Facility Director, in consultation with the Veterans Integrated Service Network’s Chief of Pathology and Laboratory Medicine Service, modifies the facility’s pre-printed fecal immunochemical test label to clearly identify a space and prompt for the patient to record the date the specimen was collected.
Closure Date:
5 The Veterans Integrated Service Network Director, in consultation with the Pathology and Laboratory Medicine Service Program Office, Gastroenterology Program Office, and the Clinical Episode Review Team, evaluates the impact potential false-negative fecal immunochemical test results may have had on patients, and determines what measures need to be taken, including whether adverse event disclosures to patients are warranted.
Closure Date:
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| 23-00821-01 | Financial Efficiency Inspection of the VA Augusta Health Care System in Georgia | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of policy requirements and that all accruals are proper and valid, as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 Collaborate with the Veterans Integrated Service Network chief financial officer and network contracting office to establish a monthly prioritized listing of contract modifications and canceled orders for goods or services that have not been addressed by contracting officers to ensure modification actions are completed.
Closure Date:
3 Ensure cardholders comply with prior approval, purchase card reconciliation, and record retention requirements as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases.”
Closure Date:
4 Develop and implement processes to ensure all necessary reports are monitored routinely and appropriate steps are taken to ensure all supply chain performance measures are maintained in compliance with policy.
Closure Date:
5 Develop and implement a plan to ensure data accuracy and reliability in the Generic Inventory Package in accordance with Veterans Health Administration policy.
Closure Date:
6 Develop formalized processes for monitoring and achieving efficiency targets and using available pharmacy data to make business decisions.
Closure Date:
7 Develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration’s recommended level.
Closure Date:
8 Ensure that pharmacy staff are trained on the ScriptPro workflow system for pharmacy.
Closure Date:
9 Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $12,031,469
Total: $12,031,469
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| 22-00229-15 | Comprehensive Healthcare Inspection of the VA Pacific Islands Health Care System in Honolulu, Hawaii | Comprehensive Healthcare Inspection Program | ||
1 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:
2 The Chief of Staff evaluates and determines any additional 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 any additional reasons for noncompliance and ensures the Executive Committee of the Medical Staff recommends continuation of privileges based on Ongoing Professional Practice Evaluation results.
Closure Date:
4 The Assistant Director for Efficiency and Improvement evaluates and determines any additional reasons for noncompliance and ensures managers comply with inpatient mental health unit environmental safety requirements.
Closure Date:
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| 22-00072-16 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 4: VA Healthcare in Pittsburgh, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials files and recommends VA appointments for physicians with a history of licensure action.
Closure Date:
2 The Network Director evaluates and determines additional reasons for noncompliance and submits a Comprehensive Environment of Care compliance report to the Environment of Care Committee annually.
Closure Date:
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| 22-02667-09 | Comprehensive Healthcare Inspection of the Iowa City VA Health Care System in Iowa | Comprehensive Healthcare Inspection Program | ||
1 The System Director determines any additional reasons for noncompliance and ensures the Chief of Staff conducts institutional disclosures for applicable sentinel events.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff complete adverse event investigations within seven days and document appropriately in the Joint Patient Safety Reporting system, or the Patient Safety Manager monitors the investigations until they are completed.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs incorporate service-specific criteria in the 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 practitioners with equivalent specialized training and similar privileges complete the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures managers keep areas used by patients clean, safe, and suitable for the care, treatment, and services provided.
Closure Date:
6 The System Director determines any additional reasons for noncompliance and ensures staff monitor and document VA police response times to panic alarm testing in the Mental Health Inpatient Unit on a regular basis.
Closure Date:
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| 22-04135-06 | Comprehensive Healthcare Inspection of the Mann-Grandstaff VA Medical Center in Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures the Peer Review Committee submits accurate peer review summary analysis data quarterly to the Health Care Delivery Council.
Closure Date:
2 The Medical Center Director ensures the Health Care Delivery Council reviews the Peer Review Committee’s summary analysis quarterly and determines actionable items.
Closure Date:
3 The Medical Center Director ensures employees comply with safe work practices to eliminate or minimize exposure to potentially infectious materials.
Closure Date:
4 The Medical Center Director ensures the Inpatient Unit Nurse Manager for the medical/surgical intensive care unit restricts access to clean and sterile storerooms to authorized personnel.
Closure Date:
5 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to local mental health leaders and quality management staff.
Closure Date:
6 The Medical Center Director ensures providers complete Comprehensive Suicide Risk Evaluations following patients’ positive suicide risk screens.
Closure Date:
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| 22-03599-07 | Deficiencies in Quality Management Processes and Delays in the Communication of Test Results and Follow-Up Care at the Phoenix VA Health Care System in Arizona | Hotline Healthcare Inspection | ||
1 The Phoenix VA Health Care System Director ensures that providers are educated on conducting clinical disclosures and documenting the discussion in the patient’s electronic health record when harm is determined to be more than minor.
Closure Date:
2 The Phoenix VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, and ensures the current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.
Closure Date:
3 The Phoenix VA Health Care System Director confirms that the Peer Review Committee record formal discussions in meeting minutes, including discussion specific to changes in rating levels in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
4 The Phoenix VA Health Care System Director makes certain adverse events or close calls are entered into the Joint Patient Safety Reporting system and the facility patient safety manager completes reviews, assigns a safety assessment code score, and conducts root cause analyses in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
5 The Phoenix VA Health Care System Director evaluates the process for the communication of abnormal test results to patients and ensures that ordering providers or designees provide timely notification to patients in a manner that informs patients of the results in accordance with Veterans Health Administration policy, and monitors compliance.
Closure Date:
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15770