Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-01695-38 | Discharge Planning Deficits for a Veteran at the Malcom Randall VA Medical Center in Gainesville, Florida | Hotline Healthcare Inspection | ||
1 The Malcom Randall VA Medical Center Director reviews roles and responsibilities for interdisciplinary treatment team members and the process for communication of plans and recommendations from all clinical team members and takes action as indicated.
Closure Date:
2 The Malcom Randall VA Medical Center Director ensures clinical staff follow established policy to alert clinical team of pertinent care changes by using the additional signer functionality or other methods of communication.
Closure Date:
3 The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned occupational therapy provider involved in the discharge planning for the patient and takes follow-up action as indicated.
Closure Date:
4 The Malcom Randall VA Medical Center Director conducts a review of care rendered by the attending physician involved in the discharge planning for the patient and takes follow-up action as indicated.
Closure Date:
5 The Malcom Randall VA Medical Center Director conducts a review of care rendered by the assigned social worker involved in the discharge planning for the patient and takes follow-up action as indicated.
Closure Date:
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| 20-03700-35 | Delayed Cancer Diagnosis of a Veteran Who Died at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 The Raymond G. Murphy VA Medical Center Director ensures supervising providers oversee all clinical decisions made by residents and the oversight is reflected within the documentation, including telephone notes.
Closure Date:
2 The Raymond G. Murphy VA Medical Center Director ensures supervising providers establish a reliable way to receive alerts for the results of all tests ordered by residents.
Closure Date:
3 The Raymond G. Murphy VA Medical Center Director ensures that Primary Care and Specialty Care staff coordinate care for shared patients and evaluates the need for Outpatient Care Coordination Agreements.
Closure Date:
4 The Raymond G. Murphy VA Medical Center Director ensures that patient, family, or staff concerns regarding delay in diagnosis are entered into the patient safety reporting system and appropriate follow-up is completed.
Closure Date:
5 The Raymond G. Murphy VA Medical Center Director coordinates a comprehensive review of the patient’s care, takes action as warranted, and reconsiders an Institutional Disclosure.
Closure Date:
6 The Raymond G. Murphy VA Medical Center Director ensures consistency between the relevant prior radiological images reviewed when staff radiologists and contract teleradiologists interpret imaging scans for Raymond G. Murphy VA Medical Center patients.
Closure Date:
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| 21-00235-13 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System in Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and makes certain to review the credentials file and approve the VA appointment for physicians who had a potentially disqualifying licensure action.
Closure Date:
2 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain to designate a mental health professional to serve on each state’s suicide prevention council or workgroup.
Closure Date:
3 The Network Director determines the reasons for noncompliance and ensures that the lead Women Veterans Program Manager provides quarterly program updates to required Veterans Integrated Service Network leaders.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager conducts assessments to identify staff’s women’s health education gaps and develops or adapts educational programs, materials, or resources where gaps are identified.
Closure Date:
5 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager has Veterans Integrated Service Network-level support staff for data analysis and performance improvement projects.
Closure Date:
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| 20-01324-215 | DMLSS Supply Chain Management System Deployed with Operational Gaps That Risk National Delays | Review | ||
1 Director of the Office of Acquisitions, Logistics, and Construction: Ensure the VA Logistics Redesign office revisits its Defense Medical Logistics Standard Support system oversight and deployment processes to align them with VA’s acquisition program management framework requirements.
Closure Date:
2 Director of the Office of Acquisitions, Logistics, and Construction: Develop processes to better identify unmet high-priority business requirements and post-deployment challenges at the Captain James A. Lovell Health Care Center and future sites and to make certain that solutions are developed and implemented.
Closure Date:
3 Director of the Office of Acquisitions, Logistics, and Construction: Properly staff the VA Logistics Redesign office with personnel who possess the appropriate subject matter expertise and employ measures to improve continuity in the project management team that oversees the Defense Medical Logistics Standard Support system’s implementation.
Closure Date:
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| 20-03437-26 | Deficiencies in Select Community Care Consult (Stat) Processes During the COVID-19 Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health evaluates community care resources, facility practices, and Veterans Health Administration requirements related to stat community care consult processes and takes action as warranted to ensure that patients receive clinically indicated care in the appropriate time frame
Closure Date:
2 The Under Secretary for Health clarifies guidance to VA medical facilities for stat community care consults including the timeliness of clinical review and approval, retrieval of medical records, and administrative closure.
Closure Date:
3 The Under Secretary for Health issues guidance to VA medical facilities regarding the override process for stat community care consults to include collaboration expected between the referring provider and the designee.
Closure Date:
4 The Under Secretary for Health evaluates patient involvement in decision-making regarding clinical reviewers’ modification of the urgency status of stat community care consults to determine if the process is in alignment with Veterans Health Administration patient-centered care goals and takes action as warranted.
Closure Date:
5 The Under Secretary for Health evaluates the time frame for adjudicating and communicating clinical appeals, determines applicability to the 24-hour requirement for completing stat community care consults, and takes action as warranted.
Closure Date:
6 The Under Secretary for Health evaluates adverse event reporting processes in community care, including a review of guidance provided in the VHA National Patient Safety Improvement Handbook, 1050.01 and the VHA Patient Safety Events in Community Care: Reporting, Investigation and Improvement Guidebook for inconsistencies and takes action as warranted.
Closure Date:
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| 21-00434-233 | New Patient Scheduling System Needs Improvement as VA Expands Its Implementation | Review | ||
1 Continue to make improvements to the scheduling training as needed to address feedback from schedulers.
Closure Date:
2 Require that some schedulers from each clinic fully test the scheduling capabilities of their clinics, solicit feedback from the schedulers to identify system or process issues, and make improvements as needed
Closure Date:
3 Issue guidance to facility staff on which date fields in the new system schedulers should use to measure patient wait times.
Closure Date:
4 Develop a mechanism to track and then monitor all tickets related to the new scheduling system, and then ensure the Office of Electronic Health Record Modernization evaluates whether Cerner effectively resolved the tickets within the timeliness metrics established in the contract.
Closure Date:
5 Develop a strategy to identify and resolve additional scheduling issues in a timely manner as the Office of Electronic Health Record Modernization deploys the new electronic health record at future facilities.
Closure Date:
6 Develop a mechanism to assess whether facility employees accurately scheduled patient appointments in the new scheduling system, and then ensure facility leaders conduct routine scheduling audits.
Closure Date:
7 Evaluate whether patients received care within the time frames directed by Veterans Health Administration policy when scheduled through the new system.
Closure Date:
8 Provide guidance to schedulers to consistently address system limitations until problems are resolved.
Closure Date:
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| 20-02908-21 | Alleged Misconduct by Construction and Facilities Deputy Executive Director Not Substantiated | Administrative Investigation | ||
1 The Executive Director of the Office of Construction and Facilities Management determines whether conducting special reviews should be conducted by the Quality Assurance Service, and if so, establishes policy or procedures to govern this type of work, including standardized processes for communicating and tracking the implementation of recommendations.
Closure Date:
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| 21-01682-25 | Inadequate Care Coordination for a Mental Health Residential Rehabilitation Treatment Program Resident in VISN 20, Oregon | Hotline Healthcare Inspection | ||
1 The Southern Oregon Rehabilitation Center and Clinics Director conducts an assessment to ensure all applicable elements of the Southern Oregon Rehabilitation Center and Clinics continuing care plan template are addressed when discharging residents from the Mental Health Residential Rehabilitation Treatment Program and takes action as warranted.
Closure Date:
2 The Southern Oregon Rehabilitation Center and Clinics Director ensures discharges of residents from the Mental Health Residential Rehabilitation Treatment Program occur during regular business hours in accordance with Veterans Health Administration Directive 1162.02.
Closure Date:
3 The Southern Oregon Rehabilitation Center and Clinics Director reviews Southern Oregon Rehabilitation Center and Clinics transportation policies to ensure alignment with Veterans
Health Administration transportation directives, including management of the transport of residents with behavioral flags.
Closure Date:
4 The Southern Oregon Rehabilitation Center and Clinics Director develops a process to ensure an updated medical evaluation is conducted should the admission team be notified of a change in
medical status that occurs after a veteran’s initial admission screening medical evaluation but prior to admission to the Mental Health Residential Treatment Program.
Closure Date:
5 The Southern Oregon Rehabilitation Center and Clinics Director completes a systematic review of residents’ falls in the shower area on the Mental Health Rehabilitation Residential Program units and takes action as warranted.
Closure Date:
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| 20-04237-09 | Audit of VA’s Compliance under the DATA Act of 2014 | Audit | ||
1 Continue the system modernization efforts that provide VA with the capability to generate the required DATA Act reporting files containing the necessary elements to meet compliance with the DATA Act. Ensure the modernization will provide the following:
a. Accurate reporting of object class, program activity codes, program activity names, and all other elements required by the DATA Act.
b. Award identification to allow VA to be able to develop a File C and reconcile the File C to both summary level data (Files A and B) and award level data (File D).
c. Reconciliations with subsidiary systems.
d. A mechanism to ensure transactions are reported that currently may be excluded due to the use of 1358s.
e. Standardized data fields to allow management to record an award ID across financial and supporting systems.
f. Subsidiary systems that are consistent with USSGL or adequately mapped to USSGL to ensure transactions contain the necessary data elements/field required to meet DATA Act reporting.
g. Differentiation between direct and reimbursable amounts.
2 Implement a grants management solution across all of VA’s grant programs and develop processes to ensure integration with the new reporting system.
Closure Date:
3 Improve researching of all root causes of differences between the VBA source systems and the monthly GTAS balances as part of their File B reconciliations. Also, differences should be accumulated and assessed at an aggregate level. The total differences either allocated to programs, reclassified out of other programs, or attributed to MinX JVs should be researched and reported as part of the SAO sub-certification process.
4 Continue mapping efforts and ensure programs without entitlement codes are recorded with the correct program activity codes and names rather than defaulting to Compensation.
5 Work with component level SAO’s to ensure timely receipt of signed certifications.
Closure Date:
6 Include more information in the SAO certifications, the Data Quality Plan document and the data submission about the costing and aggregation methodologies VA uses to report VHA data to increase transparency.
Closure Date:
7 Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for DATA Act reporting. The internal controls should ensure the following:
a. Excluded payments not reported due to zip code issues are researched, cleared, and reported in VBA’s life insurance FABS submission.
b. The default code “90” for Congressional District is not used when the county or zip code are unknown; instead, perform research to obtain the required data.
c. Guidance from OMB and Treasury is requested on the proper reporting of the face amount of insurance policies in VBA’s FABS submissions.
d. Management’s policies and procedures (e.g., Standard Operating Procedures) and narratives are updated on a timely basis in coordination with the VA PMO for the most current DATA Act submission procedures and reporting requirements.
Closure Date:
8 Ensure that reconciliations are complete, reconciling items are identified and researched, and any resolutions are clearly documented.
Closure Date:
9 Investigate potential controls or processes that could identify 1358s that should be reported until the system modernization can implement a solution.
10 Implement internal controls and update policies and procedures to improve the accuracy of and completeness of the information submitted for FABS reporting. The update should include and adhere to all FABS and DAIMS reporting requirements.
Closure Date:
11 Improve reviewing and validating eCMS actions to underlying contract documentation to assess the completeness and accuracy of data stored in eCMS. Identified exceptions should continue to be documented, and appropriate corrective actions (e.g., adequate training and guidance) should be completed to ensure and improve completeness and accuracy of data stored in eCMS.
Closure Date:
12 Coordinate and report system errors to Treasury on an as needed basis to ensure all required or derivable data elements are reported for FABS submission.
Closure Date:
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| 21-00275-11 | Comprehensive Healthcare Inspection of the Orlando VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Staff regularly attends Facility Surgical Workgroup meetings.
Closure Date:
2 The System 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:
3 The Chief of Staff and Associate Director for Patient Care Services evaluate and
determine any additional reasons for noncompliance and ensure all required
representatives attend Disruptive Behavior Committee meetings.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the required prevention and management of disruptive behavior training based on the risk level assigned to their
work areas.
Closure Date:
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14957