Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-02725-132 | Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director reviews processes in place to ensure proper response to future medical emergencies in outpatient clinics to include staff training, emergency notification systems, and emergency documentation processes.
Closure Date:
2 The VA Southern Nevada Healthcare System Director reviews the process for and compliance with documentation of cardiopulmonary resuscitation in outpatient clinic settings, and takes action as indicated.
Closure Date:
3 The VA Southern Nevada Healthcare System Director works with outpatient clinic leaders to ensure that all deficiencies identified in the after-action plan are completed and that compliance is monitored.
Closure Date:
4 The VA Southern Nevada Healthcare System Director consults with Office of General Counsel’s Regional Counsel to review the incident and determine if an institutional disclosure is warranted and takes action accordingly.
Closure Date:
5 The VA Southern Nevada Healthcare System Director completes an evaluation of staffs’ understanding of advance care planning, advance directives, and life-sustaining treatment decision processes, and takes action to address identified gaps.
Closure Date:
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| 22-00044-142 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 17: VA Heart of Texas Health Care Network in Arlington | Comprehensive Healthcare Inspection Program | ||
1 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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| 21-02110-138 | Review of Clinical Care Transition from the Department of Defense to the Veterans Health Administration for Service Members with Opioid Use Disorder | National Healthcare Review | ||
1 The Under Secretary for Health directs the Office of Primary Care and Office of Mental Health and Suicide Prevention to identify barriers to provider documentation of opioid use disorder in progress notes and implement solutions addressing these barriers.
Closure Date:
2 The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention determine impediments to maintaining accurate identification of opioid use disorder in electronic health record problem lists and implement policy and training to support accurate use of problem lists.
Closure Date:
3 The Under Secretary for Health confirms the Office of Primary Care and Office of Mental Health and Suicide Prevention evaluate barriers affecting provider access and use of Department of Defense treatment records in Joint Longitudinal Viewer and implement solutions.
Closure Date:
4 The Under Secretary for Health ensures the Office of Primary Care and Office of Mental Health and Suicide Prevention improve continuity of care by confirming providers are educated on the navigation and retrieval of Department of Defense treatment records in Joint Longitudinal Viewer.
Closure Date:
5 The Under Secretary for Health requires the Assistant Under Secretary for Health for Clinical Services/Chief Medical Officer to evaluate and update processes for identification of veterans with a history of opioid use disorder for the provision of opioid overdose risk mitigation strategies.
Closure Date:
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| 22-00488-81 | VA Developed Reporting Metrics for Appeals Modernization Act Decision Reviews but Could Be Clearer on Some Veterans’ Wait Times | Review | ||
1 Update the reporting methodology used in public reports to reflect the total time veterans wait for a final claims decision when their higher level reviews require a supplemental claim be established and completed due to an error.
Closure Date:
2 Revise and clearly state the measures used for calculating and reporting the average duration, from the filing of an initial claim until the claim is resolved and claimants no longer take any action under the Appeals Modernization Act claim, and ensure consistency with subsection M of the act.
Closure Date:
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| 22-02989-103 | Financial Efficiency Inspection of the VA New York Harbor Healthcare System | Financial Inspection | ||
1 The VA New York Harbor Healthcare System director to ensure that healthcare system finance office staff and initiating services are aware of policy requirements to conduct reviews on all inactive open obligations and deobligate any identified excess funds as required by VA Financial Policy, vol. 2, chap. 5, “Obligations Policy.”
Closure Date:
2 The VA New York Harbor Healthcare System director to ensure that healthcare system finance office staff and initiating services that healthcare system staff are conducting finance quality assurance reviews of obligations that were inactive for more than 90 days, as required by Veterans Health Administration Directive 1733, “VHA Finance Quality Assurance Reviews.”
Closure Date:
3 The VA New York Harbor Healthcare System director to ensure cardholders comply with record retention, prior approval, and purchase card reconciliation requirements as required by VA Financial Policy, vol. 16, chap. 1B, “Government Purchase Card for Micro-Purchases.”
Closure Date:
4 The VA New York Harbor Healthcare System director to ensure cardholders verify that vendors have removed all state and local sales taxes from orders, if applicable.
Closure Date:
5 The VA New York Harbor Healthcare System director to ensure authorizing officials implement internal controls over government purchase card activities to ensure compliance with the Government Purchase Card Program.
Closure Date:
6 The VA New York Harbor Healthcare System director to establish internal controls to help ensure the healthcare system monitors the Medical/Surgical Prime Vendor formulary for updates, converts supplies to the prime vendor in the item master file, identifies the prime vendor as the mandatory source for these items in the Generic Inventory Package, and properly sets up Medical/Surgical Prime Vendor supply items in VA’s ordering system.
Closure Date:
7 The VA New York Harbor Healthcare System director to develop a plan to improve collaboration with the prime vendor and its on-site representative to ensure adequate stock is available to meet orders, reduce the need for the healthcare system to use nonprime vendors, and communicate the healthcare system’s usage and in-stock timing needs.
Closure Date:
8 The VA New York Harbor Healthcare System director to ensure a qualified Medical/Surgical Prime Vendor contracting officer’s representative is appointed and performs the required delegated duties.
Closure Date:
9 The VA New York Harbor Healthcare System director to establish internal controls to help ensure the healthcare system submits national contract waivers and justifications prior to purchasing available formulary items from nonprime vendor sources.
Closure Date:
10 The VA New York Harbor Healthcare System director to ensure that prime vendor contract performance issues are routinely reported to the Medical Supplies Program Office and Strategic Acquisition Center using established Veterans Health Administration reporting tools.
Closure Date:
11 The VA New York Harbor Healthcare System director to develop formalized processes for monitoring and achieving identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
12 The VA New York Harbor Healthcare System director to develop and implement a plan to achieve an inventory turnover rate closer to the Veterans Health Administration’s recommended level.
Closure Date:
13 The VA New York Harbor Healthcare System director to develop and implement a plan to report the results of facility-based inventory audits of noncontrolled drug line items, and any follow-up actions taken, as required by Veterans Health Administration policy.
Closure Date:
14 The VA New York Harbor Healthcare System director establish processes to ensure compliance with the Veterans Health Administration directive which requires that B09 reconciliations are signed by the lead pharmacy technician and include appropriate supporting documentation.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $44,170,312
Total: $44,170,312
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| 22-03483-133 | Inadequate Community Living Center Processes and Training at the West Texas VA Health Care System in Big Spring | Hotline Healthcare Inspection | ||
1 The West Texas VA Health Care System Director ensures that community living center nursing staff are trained on their roles, responsibilities, and necessary actions when responding to a medical emergency.
Closure Date:
2 The West Texas VA Health Care System Director certifies that mock codes are completed within the community living center at regular intervals and include all community living center nursing staff.
Closure Date:
3 The West Texas VA Health Care System Director ensures that documentation requirements are met by community living center clinical staff and monitors compliance.
Closure Date:
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| 22-00228-127 | Comprehensive Healthcare Inspection of the Manila VA Clinic in Pasay City, Philippines | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Board recommends continuation of privileges based, in part, on Ongoing Professional Practice Evaluation results.
Closure Date:
2 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures providers complete Comprehensive Suicide Risk Evaluations on the same day as patients’ positive suicide risk screens.
Closure Date:
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| 22-02961-71 | Inspection of Information Security at the St. Cloud VA Medical Center in Minnesota | Information Security Inspection | ||
1 The assistant secretary for information and technology and chief information officer implement a more effective vulnerability management program to identify all critical security deficiencies on the network and to remediate vulnerabilities within policy timelines.
Closure Date:
2 The assistant secretary for information and technology and chief information officer implement a more effective inventory process to identify network devices.
Closure Date:
3 The assistant secretary for information and technology and chief information officer implement processes to prevent the use of prohibited software on agency devices.
Closure Date:
4 The assistant secretary for information and technology and chief information officer test the emergency power bypass during annual uninterruptible power supply testing and document results.
Closure Date:
5 The assistant secretary for information and technology and chief information officer ensure network segmentation controls are applied to all network segments with medical devices and special-purpose systems.
Closure Date:
6 The assistant secretary for information and technology and chief information officer ensure access authorization memorandums are present in all communication rooms.
Closure Date:
7 The assistant secretary for information and technology and chief information officer ensure that physical access for the data center and communication rooms are reviewed on a quarterly basis.
Closure Date:
8 The assistant secretary for information and technology and chief information officer ensure visitor access records are available and reviewed on a quarterly basis.
Closure Date:
9 The St. Cloud VA Medical Center director ensure video surveillance systems are operational and monitored for the data center.
Closure Date:
10 The St. Cloud VA Medical Center director ensure communication rooms with infrastructure equipment have adequate environmental controls.
Closure Date:
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| 22-00046-126 | Comprehensive Healthcare Inspection of the New Mexico VA Health Care System in Albuquerque | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Executive Leadership Board recommends, implements, and monitors improvement actions.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures the Protected Peer Review Committee recommends improvement actions for Level 3 peer reviews.
Closure Date:
3 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff either conduct an individual root cause analysis for all events receiving an actual or potential safety assessment code score of three or include the events in an aggregated review.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures providers with similar training and privileges complete licensed independent practitioners’ Focused Professional Practice Evaluations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend licensed independent practitioners’ continued privileges based on Ongoing Professional Practice Evaluation activities.
Closure Date:
6 The Assistant Director determines the additional reasons for noncompliance and ensures staff maintain, inspect, and test biomedical equipment according to the manufacturer’s recommendations.
Closure Date:
7 The Associate Director and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff remove supplies from shipping cartons and corrugated boxes prior to putting them in clean storage areas.
Closure Date:
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| 22-02960-70 | Inspection of Information Security at the James E. Van Zandt VA Medical Center in Altoona, Pennsylvania | Information Security Inspection | ||
1 Verify and make necessary corrections to the systems’ component inventory in the VA’s Enterprise Mission Assurance Support Service.
Closure Date:
2 Improve vulnerability management processes to ensure system changes occur within organization timelines.
Closure Date:
3 Develop and approve an authorization to operate for the special-purpose system.
Closure Date:
4 Validate that appropriate physical and environmental security measures are implemented and functioning as intended.
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15770