Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
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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.
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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.
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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.
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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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| 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.
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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.
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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.
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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.
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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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| 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.
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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.
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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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| 22-00071-216 | 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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| 22-00414-113 | Oversight Could Be Strengthened for Non-VA Healthcare Providers Who Prescribe Opioids to Veterans | Audit | ||
1 Clarify roles and responsibilities of the Office of Integrated Veteran Care and third-party administrators with respect to ensuring non-VA providers receive and certify they have reviewed Opioid Safety Initiative guidelines in accordance with the John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018 and collaborate with the contracting office to modify the contracts as appropriate.
Closure Date:
2 Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of the VA Opioid Safety Initiative training module.
Closure Date:
3 Ensure the Office of Integrated Veteran Care strengthens controls to monitor the third-party administrators to ensure non-VA providers’ completion of required prescription drug monitoring program queries
Closure Date:
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| 22-02017-224 | Review of VHA’s Oversight of Community Care Providers’ Opioid Prescribing at the Eastern Kansas Health Care System in Topeka and Leavenworth | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health collaborates with the region 2 third-party administrator to ensure that community care providers submit documentation of care to the Veterans Health Administration including treatments provided specific to opioid risk mitigation (urine drug screening, prescription drug monitoring program checks) and all prescriptions, to include urgently/emergently prescribed opioids and utine/maintenance opioid prescriptions.
Closure Date:
2 The VA Eastern Kansas Health Care System Director ensures system providers document evidence of Opioid Safety Initiative risk-mitigation strategies for patients who are on long-term opioids, as required by Veterans Health Administration policy.
Closure Date:
3 The Under Secretary for Health develops and implements action requiring community care network providers to document evidence of application of Opioid Safety Initiative risk mitigation strategies when treating a veteran to whom they have rescribed opioids, and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.
Closure Date:
4 The Under Secretary for Health develops and implements action requiring community care network providers to conduct and document completion of state prescription drug monitoring program queries consistent with VHA policy, prior to prescribing controlled substances, regardless of whether the prescriptions are urgent, emergent, routine or maintenance prescriptions and monitor compliance as part of their Community Provider Opioid Prescribing Practice reviews.
Closure Date:
5 The Under Secretary for Health considers issuing formal guidance to all Veterans Health Administration pharmacy staff regarding best practices for conducting state prescription drug monitoring program queries upon receipt of controlled substance prescriptions from community care network providers.
Closure Date:
6 The Under Secretary for Health develops and implements a process to oversee compliance of VHA’s medication reconciliation process for patients receiving care in the community who are prescribed opioids to include recording of the prescriptions in the non-VA medication section of the medication profile.
Closure Date:
7 The Under Secretary for Health considers options and implements a process for including non VA medications prescribed by community care providers in the data populating the opioid safety tools.
Closure Date:
8 The VA Eastern Kansas Health Care System Director ensures that medications known to system staff are entered into the patient’s medication profile in the electronic health record.
Closure Date:
9 The VA Heartland Network Director ensures the Veterans Integrated Service Network Community Care Oversight Council conducts oversight of community care network providers’ opioid prescribing practices and reports results through the Opioid Prescribing Community Providers’ SharePoint site.
Closure Date:
10 The VA Heartland Network Director confirms that the VA Eastern Kansas Health Care System has a local process outlining expectations, roles, and responsibilities for completing reviews of community care network provider’s opioid prescribing practices and that the process is shared with system staff, initiated, and monitored.
Closure Date:
11 The VA Eastern Kansas Health Care System Director continues efforts to recruit and hire staff to fill vacant pain management positions.
Closure Date:
12 The Under Secretary for Health consults with the Office for Integrated Veteran Care to determine the value of including a review of community care network provider documentation for evidence of prescription drug monitoring program queries as a required element in VA’s Guidance for Community Provider Opioid Prescribing Practices Review.
Closure Date:
13 The VA Eastern Kansas Health Care System Director ensures system staff and leaders are educated on the processes to report patient safety concerns involving community care network providers.
Closure Date:
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| 22-02936-175 | Improvements Needed for VBA’s Claims Automation Project | Review | ||
1 Implement technology improvements and demonstrate progress to ensure the accuracy and completeness of information on the hypertension summary sheet.
Closure Date:
2 Implement a process to communicate any change in policy, procedure, or the claims processing manual associated with all automated diagnostic codes between the Office of Automated Benefits Delivery, the Office of Policy and Oversight, the Office of Field Operations, and Compensation Service to ensure guidance is clear and consistent for all claims processors.
Closure Date:
3 Implement an improved quality assurance process and monitor the results to ensure the accuracy of hypertension summary sheets and final decisions.
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4 Create or amend metrics to compare the timeliness of claims processing using automation tools versus the traditional process.
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15770