Recommendations
2111
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-00043-39 | Comprehensive Healthcare Inspection of the El Paso VA Health Care System in Texas | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager conducts a root cause analysis or includes the patient safety event in an aggregate review for all events assigned an actual or potential safety assessment code score of three.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and ensures that practitioners with similar training and privileges complete Focused 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 Clinical Executive Board reviews and recommends licensed independent practitioners for reprivileging based on individual practitioners’ Ongoing Professional Practice Evaluations and documents its decisions in meeting minutes.
Closure Date:
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| 21-03308-24 | Comprehensive Healthcare Inspection of the Lexington VA Health Care System in Kentucky | Comprehensive Healthcare Inspection Program | ||
1 The Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee recommends improvement actions for all Level 3 peer reviews.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers with similar training and privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs’ determinations to continue current privileges are based on Ongoing Professional Practice Evaluation activities.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Committee’s decision to recommend continuation of privileges is based on Ongoing Professional Practice Evaluation results.
Closure Date:
6 The Director evaluates and determines any additional reasons for noncompliance and ensures staff have a current local intranasal naloxone policy.
Closure Date:
7 The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain managers adhere to commercial product expiration dates in the community living center.
Closure Date:
8 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures managers keep furnishings safe and in good repair.
Closure Date:
9 The Chief of Staff and Associate Director of Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff develop abatement plans to minimize risks for suicide and suicide attempts in acute inpatient mental health units.
Closure Date:
10 The Director evaluates and determines any additional reasons for noncompliance and ensures providers complete 100 percent of required universal and setting-specific screenings and Comprehensive Suicide Risk Evaluations.
Closure Date:
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| 21-03630-250 | Improvements Needed to Reduce Duplicate Payments by VHA and Medicare and Ensure VHA Has Authorized Community Medical Services | Review | ||
1 Work with the Centers for Medicare and Medicaid Services to establish a data sharing agreement with VA to limit potential duplicate claim payments.
Closure Date:
2 Identify overpayments made for care provided to dual eligible veterans that were not authorized by VHA and ensure either documentation of care is completed, or VA seeks reimbursement for any care without prior approval.
Closure Date:
3 Make sure all nonemergent community care is preauthorized and that documentation for all authorizations is complete and properly stored before treatment is provided.
Closure Date:
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| 21-03063-04 | VBA’s Compensation Service Did Not Fully Accommodate Veterans with Visual Impairments | Review | ||
1 Update the process for developing, approving, and issuing guidance for accommodating veterans with visual impairments to include steps for consulting with the Office of General Counsel; Office of Resolution Management, Diversity and Inclusion; and the Department of Justice Civil Rights Division.
Closure Date:
2 Coordinate with the Office of General Counsel; Office of Resolution Management, Diversity and Inclusion; and the Department of Justice Civil Rights Division to bring the existing Veterans Benefits Administration’s Adjudication Procedures Manual for accommodating veterans with visual impairments into compliance with38 C.F.R. § 14.500, VA Directive 5975, and Executive Order 12250.
3 Develop and implement a quality assurance mechanism to ensure compliance with accessibility requirements, including mandated telephone calls to veterans with visual impairments.
Closure Date:
4 Assign accessibility coordinators, publicize their names, and conduct a self-evaluation of policies as outlined in VA accessibility requirements.
5 Coordinate a process to ensure veterans with visual impairments are informed of the availability of accommodations, regardless of their level of disability.
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| 21-03309-23 | Comprehensive Healthcare Inspection of the Louisville VA Medical Center in Kentucky | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures governing committees report to the Executive Leadership Council.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures peer reviewers consistently use at least one of the nine aspects of care when conducting peer reviews.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers implement improvement actions recommended by the Peer Review Committee.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete Focused Professional Practice Evaluations within clearly defined time frames.
Closure Date:
5 The Associate Director for Operations evaluates and determines any additional reasons for noncompliance and makes certain that managers maintain a safe and clean environment.
Closure Date:
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| 21-03311-15 | Comprehensive Healthcare Inspection of the Mountain Home VA Healthcare System in Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The System Director determines the reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met.
Closure Date:
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| 21-00175-19 | Deficiencies in Lethal Means Safety Training, Firearms Access Assessment, and Safety Planning for Patients with Suicidal Behaviors by Firearms | National Healthcare Review | ||
1 The Under Secretary for Health ensures compliance with suicide risk and lethal means safety training requirements.
Closure Date:
2 The Under Secretary for Health evaluates the efficacy of the May 2022 Veterans Integrated Service Network and Office of Mental Health and Suicide Prevention oversight structure for suicide risk training and considers inclusion of an oversight structure for lethal means safety training compliance.
Closure Date:
3 The Under Secretary for Health evaluates the adequacy of the one-time lethal means safety training requirement and takes action as appropriate.
Closure Date:
4 The Under Secretary for Health ensures clinician completion of comprehensive suicide risk evaluations including the discussion and documentation of firearms access and safe storage as required, and monitors compliance.
Closure Date:
5 The Under Secretary for Health ensures clinician completion of safety plans including the discussion and documentation of firearms access and safe storage, as applicable, and monitors compliance.
Closure Date:
6 The Under Secretary for Health evaluates staff’s perceived barriers to completion of the suicide risk identification strategy and takes action as appropriate.
Closure Date:
7 The Under Secretary for Health considers initiatives to evaluate and address educational and cultural barriers to conducting and documenting patient discussions related to firearms access and safe storage practices.
Closure Date:
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| 21-03777-218 | VHA Progressed in the Follow-Up of Canceled Appointments during the Pandemic but Could Use Additional Oversight Metrics | Review | ||
1 Monitor facility follow-up rates by type of care and on a month-over-month basis, establish monitoring metrics, and assist facilities if they fall below these metrics.
Closure Date:
2 Evaluate and update, as appropriate, whether activities that occurred before cancellation and notations of “No Action Other Reason” should be tracked as follow-up.
Closure Date:
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| 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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15218