Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-03312-114 | Comprehensive Healthcare Inspection of the Tennessee Valley Healthcare System in Nashville | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director determines the reasons for noncompliance and ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures staff complete final peer reviews within 120 calendar days or approves a written extension request.
Closure Date:
3 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that for all patient safety events assigned an actual or potential safety assessment code score of three, the Patient Safety Manager conducts an individual root cause analysis or includes the events in an aggregate review.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs use Focused Professional Practice Evaluation criteria that are defined in advance and accepted by the practitioners.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Medical Executive Committee reviews professional practice evaluations for licensed independent practitioners’ privileging requests and documents the review in meeting minutes.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs establish service-specific criteria for reprivileging decisions.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs recommend reprivileging based, in part, on Ongoing Professional Practice Evaluations completed by practitioners with similar training and privileges.
Closure Date:
8 The Deputy Health System Director evaluates and determines any additional reasons for noncompliance and ensures staff identify and minimize physical environmental risks to reduce suicide or suicide attempts in acute inpatient mental health units.
Closure Date:
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| 22-00037-117 | Comprehensive Healthcare Inspection of the West Texas VA Health Care System in Big Spring | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs’ recommendations to continue current privileges are based on Ongoing Professional Practice Evaluation activities.
Closure Date:
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| 22-01116-110 | Deficient Care of a Patient Who Died by Suicide and Facility Leaders’ Response at the Charlie Norwood VA Medical Center in Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Charlie Norwood VA Medical Center Director ensures primary care teams adhere to Veterans Health Administration policies related to mental health screenings, consult management, and care coordination, and monitors compliance.
Closure Date:
2 The Charlie Norwood VA Medical Center Director reviews processes for consult scheduling, including community care referrals, and ensures patients are offered timely appointments in the pain management clinic, per Veterans Health Administration policies.
Closure Date:
3 The Charlie Norwood VA Medical Center Director confirms pain management clinic staff receive education of Veterans Health Administration policies related to mandatory suicide risk assessments.
Closure Date:
4 The Charlie Norwood VA Medical Center Director develops a process to ensure that Emergency Department staff communicate patients’ referral information from the Veterans Crisis Line to Emergency Department providers.
Closure Date:
5 The Charlie Norwood VA Medical Center Director ensures that suicide prevention staff documentation is complete and accurate, and actions are taken to resolve issues identified in Veterans Crisis Line referrals prior to closure.
Closure Date:
6 The Charlie Norwood VA Medical Center Director reviews Veterans Health Administration policy and guidance regarding completed suicides on VA campuses and actions required as a result, and provides education to relevant staff.
Closure Date:
7 The Charlie Norwood VA Medical Center Director ensures completion of accurate and comprehensive Behavioral Health Autopsies and Family Interview Tool Contact forms.
Closure Date:
8 The Charlie Norwood VA Medical Center Director reviews and evaluates the peer review process to ensure peer reviews are conducted according to Veterans Health Administration policy.
Closure Date:
9 The Charlie Norwood VA Medical Center Director reviews and evaluates the February 2022 clinical review to identify open actions and monitors the implementation and efficacy of action items to closure.
Closure Date:
| ||||
| 22-00041-105 | Comprehensive Healthcare Inspection of the Central Texas Veterans Health Care System in Temple | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons fornoncompliance and ensures leaders conduct institutional disclosures for allapplicable sentinel events.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons fornoncompliance and ensures service chiefs complete Ongoing Professional PracticeEvaluations.
Closure Date:
| ||||
| 21-03101-73 | VHA Can Improve Controls Over Its Use of Supplemental Funds | Audit | ||
1 Assess the iFAMS configuration to determine whether integration with the payroll subsystems can be accomplished to resolve some of the payroll-related issues that require the need for expenditure transfers.
Closure Date:
2 Establish guidance that outlines the type of documentation required to support the amounts identified in the manual journal vouchers when processing expenditure transfers.
Closure Date:
3 Require medical facility staff have documented authority, through proper delegation, to make purchases.
Closure Date:
4 Verify that medical facility staff segregate duties so that the same person is not both authorizing and receiving goods and services.
Closure Date:
5 Make certain the purchase card holder is not the requestor or approver for the purchase.
Closure Date:
6 Ensure contracting officer’s representatives know and understand their duties and responsibilities for the certification and payment of invoices.
Closure Date:
7 Check vendors’ compliance with contract terms to include the comparison of invoiced amounts with the contract line-item unit costs.
Closure Date:
8 Ensure that medical facility staff track the receipt of goods to make certain they are the correct quantity.
Closure Date:
9 Conduct an assessment of lessons learned from the emergency response to the pandemic and develop appropriate action plans to integrate oversight roles, responsibilities, and clear guidance into the use of supplemental funds.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $187,200,000
Total: $187,200,000
| ||||
| 22-02188-109 | Mental Health Emergency Response Documentation Inaccuracy, and Policy and Practice Inconsistencies at the VA San Diego Healthcare System in California | Hotline Healthcare Inspection | ||
1 The VA San Diego Healthcare System Director ensures the accuracy of code green documentation.
Closure Date:
2 The VA San Diego Healthcare System Director evaluates the VA San Diego Healthcare System Memorandum 116A-06, “Code Green/Code Yellow,” and aligns definitions, requirements, and responsibilities with purpose and practice, and monitors compliance.
Closure Date:
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| 22-00514-108 | Failure of Leaders to Respond to Reports of Sexual Harassment at the VA Black Hills Health Care System in Fort Meade and Hot Springs, South Dakota | Hotline Healthcare Inspection | ||
1 The VA Black Hills Health Care System Director reviews the sexual harassment policy to ensure that leaders and supervisors can identify, thoroughly investigate, and respond to sexual harassment allegations.
Closure Date:
2 The VA Black Hills Health Care System Director reviews the actions of the Compensated Work Therapy and Transitional Residence program manager related to the identified patient’s case and takes action as needed.
Closure Date:
3 The VA Black Hills Health Care System Director ensures that facility policy addresses the safety and rights of patients who are both VA employees and participants in the Transitional Residence program.
Closure Date:
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| 22-00540-107 | Issues Related to an Administrative Investigation Board at the VA Black Hills Health Care System in Fort Meade and Hot Springs, South Dakota | Hotline Healthcare Inspection | ||
1 The VA Black Hills Health Care System Director continues to monitor and track the identified action plan through to completion.
Closure Date:
2 The VA Black Hills Health Care System Director reviews the evidence and independently determines if the state licensing board should be notified.
Closure Date:
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| 22-00047-106 | Comprehensive Healthcare Inspection of the VA Long Beach Healthcare System in California | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define Focused Professional Practice Evaluation criteria in advance using objective criteria accepted by the practitioner.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Medical Executive Council reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
Closure Date:
3 The Deputy Director evaluates and determines any additional reasons for noncompliance and ensures managers keep furnishings and equipment safe and in good repair.
Closure Date:
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| 21-02805-102 | Review of Access to Telehealth and Provider Experience in VHA Prior to and During the COVID-19 Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health evaluates provider knowledge and utilization of VA Video Connect technology, including resources such as the Digital Divide Consult, Connected Devices Support Program, and VVC Now and takes action as indicated.
Closure Date:
2 The Under Secretary for Health evaluates availability of clinical and administrative support to providers initiating and completing VA Video Connect encounters and clarifies expectations and requirements to ensure access to virtual care emulates in-person encounters.
Closure Date:
3 The Under Secretary for Health ensures education of providers and support staff regarding VA Video Connect scheduling processes.
Closure Date:
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15770