Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-03086-70 | First-Party Billing Address Management Needs Improvement to Ensure Veteran Debt Notification before Collection Actions | Review | ||
1 Develop and execute a project management plan to evaluate and correct Veterans Health Information Systems and Technology Architecture address data used to mail first-party billing statements.
Closure Date:
2 Establish controls to periodically review and reconcile Veterans Health Information Systems and Technology Architecture address data used to mail first-party billing statements.
3 Improve policies detailing roles, responsibilities, and procedures for remediating returned billing statements and steps for flagging and updating outdated billing addresses
Closure Date:
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| 21-01724-84 | Care in the Community Consult Management During the COVID-19 Pandemic at the Martinsburg VA Medical Center in West Virginia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director confirms that weekly calls with facility and Veterans Integrated Service Network leaders are held to discuss active Improvement Action Plans, progress made, timelines, and next steps.
Closure Date:
2 The Martinsburg VA Medical Center Director verifies that Improvement Action Plans, identifying areas of improvement and outlining recommendations, are in place for unmet national Care in the Community performance metrics.
Closure Date:
3 The Martinsburg VA Medical Center Director ensures COVID Priority 1 consults are run and reviewed by Care in the Community managers and staff daily.
Closure Date:
4 The Martinsburg VA Medical Center Director confirms that clinical reviews of COVID Priority 1 active consults are completed and documented, monitors compliance, and takes action as warranted.
Closure Date:
5 The Martinsburg VA Medical Center Director ensures a process is in place to review and address consults for patients who died prior to being scheduled or seen by a community care provider to determine if an adverse event occurred as a result of a delay in processing a patient’s consult.
Closure Date:
6 The Martinsburg VA Medical Center Director evaluates the effectiveness of strategies to manage the backlog of active consults and the use of urgent and emergent to prioritize consults for scheduling, determines if changes in practice are warranted, and documents the agreed upon process.
Closure Date:
7 The Martinsburg VA Medical Center Director conducts a review to determine who, outside Care in the Community staff, is facilitating appointment scheduling and evaluates if the scheduling assistance of other services is an effective use of resources, and establishes a standardized process to align practices.
Closure Date:
8 The Martinsburg VA Medical Center Director ensures Care in the Community staffing levels are adequate to support the processing of consults according to time frames set by the Veterans Health Administration.
Closure Date:
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| 21-02492-77 | Lack of Care Coordination and Hepatocellular Carcinoma Surveillance of a Patient at the VA Eastern Colorado Health Care System in Aurora | Hotline Healthcare Inspection | ||
1 The VA Eastern Colorado Health Care System Director reviews the transition in care process for patients transferring between primary care providers to ensure continuous care that facilitates communication and avoids missed opportunities, and takes action as warranted.
Closure Date:
2 The VA Eastern Colorado Health Care System Director ensures that providers develop and update patient problem lists as required and monitors compliance.
Closure Date:
3 The VA Eastern Colorado Health Care System Director ensures that primary care providers are educated on the expectations of reviewing a patient’s electronic health record when assuming care of an established patient.
Closure Date:
4 The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient’s care by the primary care providers, determines if an adverse event occurred, and takes action as warranted.
Closure Date:
5 The VA Eastern Colorado Health Care System Director conducts a clinical review of the patient identified during the inspection who did not receive hepatocellular carcinoma surveillance or varices monitoring, determines if an adverse event occurred, and takes action as warranted.
Closure Date:
6 The VA Eastern Colorado Health Care System Director ensures that patients requiring hepatocellular carcinoma surveillance and varices monitoring receive the recommended imaging studies, lab tests, and esophagogastroduodenoscopies, and monitors compliance.
Closure Date:
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| 21-00298-72 | Comprehensive Healthcare Inspection of the VA Hudson Valley Health Care System in Montrose, New York | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the referring physician includes all required elements on the VA Inter-Facility Transfer Form or facility-defined equivalent note in the patient’s electronic health record.
Closure Date:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure staff send pertinent medical records to the receiving facility during inter-facility transfers.
Closure Date:
5 The Associate Director for Patient Care Services determines any additional reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between sending and receiving facilities.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required trainings.
Closure Date:
7 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 areas.
Closure Date:
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| 21-00276-67 | Comprehensive Healthcare Inspection of the Durham VA Health Care System in North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that credentialing staff complete primary source verification of all registered nurses’ licenses prior to initial appointment.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
3 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that inter-facility transfers are monitored and evaluated.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that appropriately privileged providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note, and document all required elements prior to patient transfers.
Closure Date:
5 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that transferring providers send patients’ active medication lists to receiving facilities.
Closure Date:
6 The Chief of Staff and Associate Director Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required members attend Disruptive Behavior Committee meetings.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Disruptive Behavior Committee documents patient notification for an Order of Behavioral Restriction in the Disruptive Behavior Reporting System.
Closure Date:
8 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete the assigned prevention and management of disruptive behavior training based on the risk level assigned to their work area.
Closure Date:
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| 21-00292-73 | Comprehensive Healthcare Inspection of the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff regularly attends Surgical Work Group meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent prior to patient transfer.
Closure Date:
4 The Associate Director of 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:
5 The Medical Center 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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| 21-02489-69 | Inspection of Sterile Processing Services at the Carl T. Hayden VA Medical Center in Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Carl T. Hayden VA Medical Center Director ensures that staff comply with requirements for donning required personal protective equipment prior to entry into decontamination areas.
Closure Date:
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| 21-01507-61 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Medication Management in Veterans Health Administration Facilities, Fiscal Year 2020 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers complete aberrant behavior risk assessments on all patients prior to initiating long-term opioid therapy.
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers document justification for prescribing opioids and benzodiazepines concurrently.
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers consistently conduct urine drug testing as recommended for patients on long-term opioid therapy.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers communicate problematic urine test results to patients.
5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facility providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facility providers follow up with patients within three months after initiating opioid therapy to assess adherence to the pain management plan of care and effectiveness of interventions.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities monitor the quality of pain assessment and effectiveness of pain management interventions.
Closure Date:
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| 21-00497-46 | Audit of Community Care Consults during COVID-19 | Audit | ||
1 Develop guidelines requiring supervisors to use VHA systems to monitor documentation of efforts to contact patients to schedule an appointment and to take corrective action as appropriate.
Closure Date:
2 Establish a tool to monitor whether clinicians are properly indicating the appropriateness of alternative forms of care and whether staff offered them to patients when clinically appropriate.
Closure Date:
3 Reassess the frequency of and approach to its training for scheduling community care consults to VHA facilities as revisions are made to the various tools.
Closure Date:
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| 20-00552-30 | VA’s Use of the Defense Logistics Agency’s Electronic Catalog for Medical Items | Review | ||
1 Update the Electronic Catalog Ordering Guide with additional guidance to clarify the requirement to consider Federal Supply Schedule contracts before ordering medical supplies and equipment through the Defense Logistics Agency’s Electronic Catalog and monitor compliance.
Closure Date:
2 Establish a process to monitor orders through the Defense Logistics Agency’s Electronic Catalog to identify recurring acquisitions that could be purchased through other contract vehicles at a lower price.
Closure Date:
3 Require a justification for every order through the Defense Logistics Agency’s Electronic Catalog if a Federal Supply Schedule contract is available.
Closure Date:
4 Correct and monitor compliance with the Rule of Two diagram in the Electronic Catalog Ordering Guide.
Closure Date:
5 Establish a process to ensure appropriate documentation and audits of orders in accordance with the Electronic Catalog Ordering Guide.
Closure Date:
6 Conduct and document annual reviews as required in the interagency agreement.
Closure Date:
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14957