Recommendations
2083
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-01821-08 | Care in the Community Healthcare Inspection of VA Heartland Network (VISN 15) | Care in the Community Healthcare Inspection | ||
1 The VISN 15 Network Director ensures that an end-stage renal disease provider sees patients enrolled in the home dialysis program at least monthly, as evidenced by a progress note placed in the medical record and endorsed by the responsible independent renal practitioner.
Closure Date:
2 The VISN 15 Network Director makes certain that staff ensure home visits are performed prior to accepting patients into the home dialysis program, and at least annually thereafter.
Closure Date:
3 The VISN 15 Network Director ensures VISN leaders and clinicians monitor the quality of contracted clinical services for patients receiving non-VA home dialysis services.
Closure Date:
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| 22-01440-254 | Review of VA’s Staffing and Vacancy Reporting under the MISSION Act of 2018 | Review | ||
1 Consider seeking legislative relief from Congress regarding the language related to
reporting potential hires under the element of section 3008(a)(E)(iii) of the Johnny
Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act
of 2020.
Closure Date:
2 Absent such relief, provide information detailing the limitations that prevent VA from reporting the average number of days that potential title 38 or hybrid title 38 hires spent in each phase of the hiring model in accordance with section 3008(a)(E)(iii) of the Johnny Isakson and David P. Roe, M.D. Veterans Health Care and Benefits Improvement Act of 2020.
Closure Date:
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| 21-03924-234 | Additional Actions Needed to Fully Implement and Assess the Impact of the Patient Referral Coordination Initiative | Review | ||
1 Assign specific roles and responsibilities to the Office of Integrated Veteran Care to ensure effective oversight of the Referral Coordination Initiative.
Closure Date:
2 Make certain that staff with Referral Coordination Initiative responsibilities are sufficiently trained on how to triage, communicate key information on options to veterans, schedule, or document consults, according to their respective duties.
Closure Date:
3 Direct relevant VA medical facilities to establish local processes by which VA medical facility staff identify and share available community care wait time data with referral coordination team members within each facility, and then establish controls to help ensure that this information is consistently communicated to patients.
Closure Date:
4 Establish a mechanism or update the Referral Coordination Initiative checklist to effectively track and monitor each facility’s challenges with implementation and progress toward implementing the initiative for all relevant specialty services.
Closure Date:
5 Develop and then disseminate to all relevant VA medical facilities best practices and lessons learned for implementing the Referral Coordination Initiative.
Closure Date:
6 Make sure that VA medical facility staff are completely and accurately tracking andmonitoring consults processed through the Referral Coordination Initiative using theConsult Toolbox 2.0 or the most current system and version.
Closure Date:
7 Develop measures and processes to assess whether facility staff are meeting the Referral Coordination Initiative’s intent of reducing scheduling times, providing veterans with key information, and minimizing facility providers’ administrative burden of managing consults.
Closure Date:
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| 22-00818-03 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2021 | Comprehensive Healthcare Inspection Program | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility peer review committees recommend improvement actions for Level 3 peer reviews.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility surgical work groups meet monthly and core members consistently attend meetings.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility surgical work groups consistently review surgical deaths.
Closure Date:
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| 22-00811-07 | Comprehensive Healthcare Inspection Summary Report: Evaluation of High-Risk Processes in Veterans Health Administration Facilities, Fiscal Year 2021 | Comprehensive Healthcare Inspection Program | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that chiefs of staff and associate directors for patient care services ensure all required members attend disruptive behavior committee or board meetings.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that chiefs of staff ensure disruptive behavior committees or boards document patient notification of Orders of Behavioral Restriction in the Disruptive Behavior Reporting System.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that medical center directors ensure staff complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
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| 22-00813-253 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2021 | Comprehensive Healthcare Inspection Program | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
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| 21-00797-248 | Intimate Partner Violence Assistance Program Implementation Status and Barriers to Compliance | National Healthcare Review | ||
1 The Under Secretary for Health ensures that Intimate Partner Violence Assistance Program protocols are developed at all medical centers consistent with the national requirement.
Closure Date:
2 The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding Intimate Partner Violence Assistance Program coordinators’ dedicated time and population needs, and takes action as warranted.
Closure Date:
3 The Under Secretary for Health determines the appropriate guidance for dedicated administrative staff support in consideration of the Intimate Partner Violence Assistance Program coordinators’ responsibilities, and takes action as warranted.
Closure Date:
4 The Under Secretary for Health considers the establishment of standardized Intimate Partner Violence staff training content and format as well as the evaluation of training efficacy, and takes action as warranted.
Closure Date:
5 The Under Secretary for Health develops intimate partner violence screening requirements based on the current guidance and patient population needs, and takes action as warranted.
Closure Date:
6 The Under Secretary for Health expedites standardized program evaluation processes with oversight and reporting responsibilities to ensure identification of implementation and program deficiencies and monitoring of corrective action and performance improvement plans.
Closure Date:
7 The Under Secretary for Health evaluates the current guidance and operational status related to the roles and oversight functions of the Veterans Integrated Service Network Intimate Partner Violence Assistance Program champions and lead coordinators and clarifies expectations and requirements.
Closure Date:
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| 21-02641-229 | Buy American Act Compliance Deficiencies at Regional Procurement Office Central | Audit | ||
1 Assess compliance weaknesses identified by VA Office of Procurement Policy, Systems and Oversight internal reviews, and implement corrective actions determined appropriate.
Closure Date:
2 Require contracting officers responsible for Buy American Act compliance deficiencies identified by contract file reviewers and VA Office of Procurement Policy, Systems and Oversight internal reviews to attend refresher Buy American Act–specific training.
Closure Date:
3 Evaluate the contract file review procedures to make certain they require the use of the Definitions of Comment Categories, and presolicitation and preaward checklists, and document that use, to strengthen compliance.
Closure Date:
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| 22-00973-215 | Inspection of Information Technology Security at the Harlingen VA Health Care Center in Texas | Information Security Inspection | ||
1 Implement a more effective process to maintain consistent inventory information for all network segments.
Closure Date:
2 Implement a vulnerability management program that ensures system changes occur within organization timelines.
Closure Date:
3 Implement effective system life-cycle processes to ensure network devices meet standards mandated by the VA Office of Information and Technology Configuration Control Board.
Closure Date:
4 Develop and implement a process to retain database logs for a period consistent with VA’s record retention policy.
Closure Date:
5 Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
Closure Date:
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| 21-03203-239 | Surgical Adverse Clinical Outcomes and Leaders’ Responses at the Columbia VA Health Care System in South Carolina | Hotline Healthcare Inspection | ||
1 The Southeast Network Director facilitates a comprehensive review of Patient A’s episode of care, from the time and date of the patient’s hospitalization through the date and time of the patient’s death, to identify practitioner and process improvements that may reduce the potential for future incidents, and takes appropriate actions.
Closure Date:
2 The Columbia VA Health Care System Director ensures providers carefully consider facility resources when evaluating medically-complex patients for admission and when determining whether admitted patients’ medical complexities exceed the facility’s capabilities to meet patients’ needs.
Closure Date:
3 The Columbia VA Health Care System Director ensures that the peer review committee record the committee members formal discussions specific to the peer review in meeting minutes, and monitors ongoing compliance.
Closure Date:
4 The Columbia VA Health Care System Director evaluates quality management practices that impede the timeliness of institutional disclosures, ensures current practices are in alignment with Veterans Health Administration policy, and takes action as warranted.
Closure Date:
5 The Columbia VA Health Care System Director ensures that root cause analyses are completed within the required 45-day time frame to promptly identify and address system vulnerabilities.
Closure Date:
6 The Columbia VA Health Care System Director facilitates a comprehensive administrative review of the vascular surgeon’s disregard of surgical and invasive procedure protocols and Stop the Line principles, consults with the Office of Regional Counsel and human resource specialists, and takes administrative actions, as appropriate.
Closure Date:
7 The Columbia VA Health Care System Director evaluates facility staff’s informed consent and time-out practices, to include the review of pertinent medical images, and ensures practices are consistent with correct surgery and invasive procedure requirements, takes action as appropriate, and monitors compliance.
Closure Date:
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15052