Recommendations
2111
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-03349-186 | Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia | Hotline Healthcare Inspection | ||
1 The Hampton VA Medical Center Director ensures that providers communicate, act on, and document a review of test results consistent with Veterans Health Administration policy.
Closure Date:
2 The Hampton VA Medical Center Director determines why the abnormal prostate-specific-antigen test results were not alerted to an ordering or surrogate provider and if other patient test results during that time frame also warrant review.
Closure Date:
3 The Hampton VA Medical Center Director ensures that abnormal test results are timely communicated to providers or providers’ surrogates.
Closure Date:
4 The Hampton VA Medical Center Director reviews the urology consult template and, if appropriate, ensures the specific imaging required for consultation is specified in the template.
Closure Date:
5 The Hampton VA Medical Center Director ensures that procedures are in place to identify and reduce errors when staff place nuclear medicine orders.
Closure Date:
6 The Hampton VA Medical Center Director ensures that facility staff submit patient safety reports consistent with Veterans Health Administration and Hampton VA Medical Center policy.
Closure Date:
7 The Hampton VA Medical Center Director ensures that quality management staff initiate timely quality reviews when deficiencies in patient care are identified.
Closure Date:
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| 22-00576-178 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2021 | Review | ||
1 The acting under secretary for health take necessary measures to reduce improper and unknown payments to below 10 percent for Beneficiary Travel, Medical Care Contracts and Agreements, Purchased Long-Term Services and Supports, and VA Community Care programs and activities.
Closure Date:
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| 21-03080-142 | Mission Accountability Support Tracker Lacked Sufficient Security Controls | Review | ||
1 The OIG recommends the Assistant Secretary for Information and Technology develop controls to help ensure minor applications are not misclassified as assets and undergo the appropriate security accreditation and certification process.
Closure Date:
2 The OIG recommends the Assistant Secretary for Information and Technology in conjunction with the Under Secretary for Benefits, make certain that appropriate security and privacy controls are implemented during the development of information technology systems before being hosted on VA’s network.
Closure Date:
3 The OIG recommends the Under Secretary for Benefits, in conjunction with the Assistant Secretary for Information and Technology, establish a mechanism to gain assurance that proper Office of Information Technology project management processes and protocols are followed when establishing information technology systems and applications.
4 The OIG recommends the Under Secretary for Benefits establish policies and procedures to ensure the Mission Accountability Support Tracker is used appropriately and does not contain unnecessary personally identifiable information.
Closure Date:
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| 21-00288-175 | Comprehensive Healthcare Inspection of the Washington DC VA Medical Center | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines reasons for noncompliance and ensures leaders identify adverse events as sentinel events when criteria are met and conduct institutional disclosures as required.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
Closure Date:
3 The Executive Director evaluates and determines any additional reasons for noncompliance and makes certain that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
4 The Associate Director, Clinical Services evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
5 The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine reasons for noncompliance and ensure staff monitor and evaluate all inter-facility transfers as part of VHA’s Quality Management Program.
Closure Date:
6 The Associate Director, Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
7 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team meetings are held and members complete training, as required.
Closure Date:
8 The Associate Director, Clinical Services and Associate Director, Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
Closure Date:
9 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures employees complete all required prevention and management of disruptive behavior training based on the risk level assigned to their work areas.
Closure Date:
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| 21-00283-173 | Comprehensive Healthcare Inspection of the VA Maryland Health Care System in Baltimore | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines additional reasons for noncomplianceand ensures that peer reviewers use at least one of the nine aspects of care forevaluations.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures that the Peer Review Committee recommendsimprovement actions for Level 3 peer reviews.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons fornoncompliance and makes certain that the Peer Review Committee completes finalpeer reviews within 120 calendar days from the date it is determined a peer reviewis required, or the System Director approves any necessary extensions in writing.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that staff monitor and evaluate all transfers as part of VHA’s Quality Management Program.
Closure Date:
5 The Chief of Staff and Associate Director for Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure that transferringproviders complete all elements of the VA Inter-Facility Transfer Form or afacility-defined equivalent note in the electronic health record.
Closure Date:
6 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
Closure Date:
7 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
8 The System Director evaluates and determines any additional reasons for noncompliance and ensures employees 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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| 21-02197-165 | Financial Efficiency Review of the VA El Paso Healthcare System in Texas and New Mexico | Financial Inspection | ||
1 Ensure healthcare system finance office staff are made aware of policy requirements for open obligations and the responsible healthcare system finance office conducts reviews on all open obligations as required by VA Financial Policies and Procedures, Volume II, Chapter 5, “Obligations Policy,” October 2020.
Closure Date:
2 Establish procedures to ensure cardholders comply with record retention and transaction-processing requirements as stated in VA’s Financial Policy, vol. XVI, “Charge Card Program.”
Closure Date:
3 Develop a plan to work with the prime vendor to address having adequate stock to meet orders, reducing the need for the healthcare system to use nonprime vendors.
Closure Date:
4 Ensure the healthcare system follows the Medical Surgical Prime Vendor-Next Generation ordering hierarchy and purchases items from the Medical Surgical Prime Vendor-Next Generation contract before using other sources.
Closure Date:
5 Ensure the healthcare system elects and is granted a delivery method that meets just-in-time requirements.
Closure Date:
6 Ensure the healthcare system submits Medical Surgical Prime Vendor-Next Generation waiver requests and obtains approval before purchasing available formulary items from nonprime vendor sources.
Closure Date:
7 Ensure logistics staff and contracting officer’s representatives use all the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance issues.
Closure Date:
8 Develop formalized processes for achieving identified efficiency targets and use available pharmacy data to make business decisions.
Closure Date:
9 Educate non-VA providers on prescribing lower-cost drugs.
Closure Date:
10 Develop and implement a plan to increase inventory turnover to the Veterans Health Administration-recommended level.
Closure Date:
11 Develop and implement a plan to complete facility-based inventory audits of noncontrolled drug line items in compliance with Veterans Health Administration policy.
Closure Date:
12 Develop a plan to ensure that appropriate metrics for monitoring compliance with Veterans Health Administration policy are calculated correctly in the Pharmacy Benefits Management inventory reporting tool.
Closure Date:
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| 21-01237-127 | Contract Medical Exam Program Limitations Put Veterans at Risk for Inaccurate Claims Decisions | Review | ||
1 Assess and modify contracts and any renewals to ensure that vendors can be heldaccountable for unsatisfactory performance by applying monetary disincentives.
Closure Date:
2 Assess and modify contracts and any renewals to ensure procedures are established for vendors to correct errors identified by the Medical Disability Examination Office.
Closure Date:
3 Implement procedures requiring the Medical Disability Examination Office tocommunicate exam errors to the Office of Field Operations and the regional officesand demonstrate progress in correcting the identified errors.
Closure Date:
4 Implement procedures requiring the Medical Disability Examination Office toanalyze all available error data and provide systemic exam issues and error trends tovendors.
Closure Date:
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| 20-02186-78 | Suicide Prevention Coordinators Need Improved Training, Guidance, and Oversight | Review | ||
1 Ensure program officials in collaboration with regional and local leaders address call management system data integrity issues before they use data to assess the management of referrals.
Closure Date:
2 Have the program office develop formal training and guidance for coordinators on how to use patient outcome codes and regional and local leaders ensure the training is completed.
Closure Date:
3 Ensure regional and local managers regularly review crisis line referral information in the electronic health records to verify coordinators are completing and documenting appropriate follow-up on referrals and the program office performs regular audits, monitors, reports upon, and initiates actions, as needed, to ensure compliance with and completion of referral follow-up.
Closure Date:
4 Consider guidance within coordinators’ training tools to clarify the expectations for coordinators to follow up on referred veterans who have been hospitalized in a non-VA hospital, admitted to an emergency department (VA and non-VA), or provided a welfare check.
Closure Date:
5 Have regional and local managers monitor coordinators’ call attempts to ensure they are interspersed over a three-day period and provide them with referral closure information to assist in their monitoring.
Closure Date:
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| 21-00286-163 | Comprehensive Healthcare Inspection of the Beckley VA Medical Center in West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Surgical Workgroup Committee meets atleast monthly.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures staff complete mandatory suicide safety plan trainingprior to developing suicide safety plans.
Closure Date:
3 The Chief of Staff and Associate Director/Patient Care Services evaluate anddetermine any additional reasons for noncompliance and ensure staff send activemedication lists to receiving facilities during inter-facility transfers.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
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| 21-00293-170 | Comprehensive Healthcare Inspection of the Hershel Woody Williams VA Medical Center in Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures leaders conduct institutional disclosures for all sentinelevents.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Systems Redesign Coordinator participates on the Quality, Safety & Value Council.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and makes certain that the Facility Surgical Work Group meets atleast monthly.
Closure Date:
4 The Medical Center Director evaluates and determines any additional reasons fornoncompliance and ensures that core members consistently attend Facility SurgicalWork Group meetings.
Closure Date:
5 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent note.
Closure Date:
6 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required representatives attend the Disruptive Behavior Committee meetings.
Closure Date:
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15218