Recommendations
2225
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-02612-53 | Delayed Cancer Diagnosis and Deficiencies in Care Coordination for a Patient at the Overton Brooks VA Medical Center in Shreveport, Louisiana | Hotline Healthcare Inspection | ||
1 The Overton Brooks VA Medical Center Director evaluates the processes for the communication of abnormal radiology imaging results and ensures patients receive timely notification, per Veterans Health Administration and facility requirements.
Closure Date:
2 The Overton Brooks VA Medical Center Director ensures oversee all clinical decisions and documentation made by residents and the oversight is reflected within the documentation.
Closure Date:
3 The Overton Brooks VA Medical Center Director reviews the processes for assigning a provider surrogate and monitors compliance.
Closure Date:
4 The Overton Brooks VA Medical Center Director ensures that concerns are entered into the Joint Patient Safety Reporting System and appropriate follow-up is completed.
Closure Date:
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| 21-03864-34 | Noncompliance with Community Care Referrals for Substance Abuse Residential Treatment at the VA North Texas Health Care System | Hotline Healthcare Inspection | ||
1 The VA North Texas Health Care System Director ensures that staff provide alternative treatment options, including community residential care referrals, when Veterans Health Administration admission wait time for substance abuse disorder residential rehabilitation treatment exceeds 30 days, and monitors compliance.
Closure Date:
2 The VA North Texas Health Care System Director conducts a comprehensive review of the management of community residential care referrals and takes action as warranted.
Closure Date:
3 The Under Secretary for Health ensures that Veterans Integrated Service Network leaders provide adequate oversight to ensure adherence to the mental health residential rehabilitation treatment program access to care policy as required.
Closure Date:
4 The VA North Texas Health Care System Director makes certain that the Bonham Substance Abuse Residential Rehabilitation Treatment Program procedures are consistent with Veterans Health Administration scheduling requirements, and monitors compliance.
Closure Date:
5 The Under Secretary for Health strengthens mental health treatment coordinator assignment procedures for patients awaiting mental health residential rehabilitation treatment program admission as warranted.
Closure Date:
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| 21-01711-50 | Improvements Recommended in Visit Frequency and Contingency Planning for Emergencies in Intensive Community Mental Health Recovery Programs | National Healthcare Review | ||
1 The Under Secretary for Health ensures the Office of Mental Health and Suicide Prevention develops, implements, and monitors action plans to meet Intensive Community Mental Health Recovery visit frequency requirements, to include program resource needs and the ongoing role for virtual care.
Closure Date:
2 The Under Secretary for Health requires the Office of Mental Health and Suicide Prevention to develop a process for Intensive Community Mental Health Recovery programs to ensure veterans receiving low-intensity services do not represent greater than 20 percent of caseloads and to distinguish between veterans receiving high- and low-intensity services for accurate and effective program oversight.
Closure Date:
3 The Under Secretary for Health identifies barriers and ensures healthcare systems develop, implement, and maintain contingency plans specific to Intensive Community Mental Health Recovery programs regarding veteran access to medications during emergencies, including long-acting injectable antipsychotic medications.
Closure Date:
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| 22-01341-43 | Mistreatment and Care Concerns for a Patient at the VA Montana Healthcare System in Miles City and Fort Harrison | Hotline Healthcare Inspection | ||
1 The Rocky Mountain Network Director reviews facility staff’s actions taken in response to the allegations and concerns related to the patients identified in this report to ensure Veterans Health Administration and facility requirements were met including Montana elder abuse reporting requirements, and takes actions, such as reporting, disciplinary actions, peer reviews, and consultation with the Office of General Counsel, as needed.
Closure Date:
2 The Montana VA Healthcare System Director ensures that the rights of community living center patients to refuse treatments or procedures are acknowledged and documented according to Veterans Health Administration requirements, and staff are educated on and adhere to the rights, as needed.
Closure Date:
3 The Montana VA Healthcare System Director reviews the nursing care provided to the identified patient with respect to quality of care, including adhering to the patient’s care plan, and reporting and documenting status changes, and takes actions as indicated.
Closure Date:
4 The Montana VA Healthcare System Director reviews the physician’s care provided to the identified patient with respect to quality of care, including documenting and reporting status changes and concerns, and takes actions as indicated.
Closure Date:
5 The Montana VA Healthcare System Director reviews community living center screening and admission evaluation processes and ensures that the processes, including documentation of admissions decisions, roles, and responsibilities are established to meet the care needs of prospective patients, and are communicated with applicable staff, as needed.
Closure Date:
6 The Montana VA Healthcare System Director reviews the patient’s acute care, including actions to address medical recommendations, and takes actions as indicated.
Closure Date:
7 The Montana VA Healthcare System Director ensures state licensing board processes related to the mistreatment incidents identified in this report are reviewed, deficiencies identified, and compliance processes completed.
Closure Date:
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| 22-00707-44 | Physician’s Falsification of VA Video Connect Blood Pressures at the North Las Vegas VA Medical Center in Nevada | Hotline Healthcare Inspection | ||
1 The North Las Vegas Medical Center Director ensures, through training and observation, that the primary care provider is competent completing and documenting primary care VA Video Connect visits.
Closure Date:
2 The North Las Vegas Medical Center Director considers taking administrative action in relation to the primary care provider, as appropriate.
Closure Date:
3 The North Las Vegas Medical Center Director considers the need to initiate reporting the primary care provider to the state licensing board and takes action as necessary.
Closure Date:
4 The North Las Vegas Medical Center Director ensures a review is conducted of the primary care provider’s electronic health record documentation in order to determine if blood pressure entries other than 120/80 are false and takes action as necessary.
Closure Date:
5 The North Las Vegas Medical Center Director ensures that any identified false blood pressures are amended in the electronic health record in accordance with Veterans Health Administration policy.
Closure Date:
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| 22-01668-45 | Poor Emergency Department Care of a Patient at the Baltimore VA Medical Center in Maryland | Hotline Healthcare Inspection | ||
1 The VA Maryland Health Care System Director ensures that Emergency Department providers conduct comprehensive clinical assessments and address patients’ presenting complaints.
Closure Date:
2 The VA Maryland Health Care System Director evaluates the process of clinical consultation for Emergency Department physician assistants and takes action as necessary.
Closure Date:
3 The VA Maryland Health Care System Director evaluates the status of action plans set forth in the facility’s review of the patient care from the second visit and institutional disclosure, monitoring the implementation and efficacy of action items to closure.
Closure Date:
4 The VA Maryland Health Care System Director evaluates and strengthens the process to ensure that problem lists reflect current and active diagnoses, and takes action as necessary.
Closure Date:
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| 21-03734-32 | Inadequate Supervision of a Mental Health Provider and Improper Records Management for a Female Patient at the VA Greater Los Angeles Health Care System in California | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director reviews the supervision provided to the psychiatry trainee regarding the patient’s treatment, documentation, and document control, to include electronic health records and video recordings, and determines if standards were met, and takes action as indicated.
Closure Date:
2 The Veterans Integrated Service Network Director reviews treatment protocols for video recorded therapy, specifically the management of patient access to recordings, and takes action as indicated.
Closure Date:
3 The Greater Los Angeles Healthcare System Director reviews the facility leader and staff responses, including those of the supervisor and patient advocate, to ensure the patient’s concerns were adequately addressed, and takes action as indicated.
Closure Date:
4 The Under Secretary for Health conducts a review to assess the possible scope of current and former VA psychiatry residents being in possession of patients’ personal health information, to include video recorded treatment sessions and consent forms, and consults with the appropriate organizational leaders such as the Office of General Counsel on the required disposition of the recordings and forms, and takes action as needed.
Closure Date:
5 The Greater Los Angeles Healthcare System Director ensures records control schedules, including one for video recordings, are completed for the Mental Health Department as required by Veterans Health Administration policy.
Closure Date:
6 The Greater Los Angeles Healthcare System Director reviews processes related to the utilization of video recordings, in consultation with appropriate staff, to ensure compliance with Veterans Health Administration requirements.
Closure Date:
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| 21-03231-38 | Vet Center Inspection of Midwest District 3 Zone 1 and Selected Vet Centers | Vet Center Inspection Program | ||
1 The District Director determines reasons annual in-service training was not provided for vet center directors, veteran outreach program specialists, and office managers and ensures training is offered for all positions as required.
Closure Date:
2 The District Director determines reasons clinical quality review remediation plans were not completed for the Grand Rapids and South Bend Vet Centers, ensures completion, and monitors compliance.
Closure Date:
3 The District Director determines reasons clinical quality review remediation plans at the four selected vet centers did not include documentation of deficiency resolution and the time frame of resolution, takes indicated actions to ensure completion, and monitors compliance.
Closure Date:
4 The District Director determines reasons for lack of evidence that clinical quality review deficiencies were resolved at the Cleveland, Columbus, and Toledo Vet Centers, takes indicated actions to ensure completion, and monitors compliance.
Closure Date:
5 The District Director determines reasons for lack of evidence for administrative quality review deficiency resolution for the Cleveland, Columbus, and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance
Closure Date:
6 The District Director determines reasons administrative quality review remediation plans did not include documentation of deficiency resolution and the time frame of resolution for the Columbus and South Bend Vet Centers, takes indicated actions to ensure completion, and monitors compliance.
Closure Date:
7 The District Director determines reasons why morbidity and mortality reviews for serious suicide attempts were not completed, ensures completion, and monitors compliance.
Closure Date:
8 The Readjustment Counseling Service Chief Officer defines “serious suicide attempt” and establishes criteria for when a morbidity and mortality review is required as well as a standardized process for completing the review.
Closure Date:
9 The District Director ensures the intake portion of the psychosocial assessment is completed and monitors compliance across all zone vet centers.
Closure Date:
10 The District Director ensures suicide risk assessments are completed on the first clinical visit and monitors compliance across all zone vet centers.
Closure Date:
11 The District Director ensures clinical staff consult and coordinate care with the support VA medical facility for shared clients flagged as high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
12 The District Director ensures clinical staff follow confidentiality requirements when consulting and coordinating care with the support VA medical facility for shared clients at high risk for suicide and monitors compliance across all zone vet centers.
Closure Date:
13 The District Director ensures clinical staff make timely notification to the suicide prevention coordinator at the support VA medical facility for clients with significant safety risks and monitors compliance across all zone vet centers.
Closure Date:
14 The District Director ensures clinical staff complete safety plans for clients who are assessed at intermediate or high suicide risk level in either acute, chronic, or both categories as required, and monitors compliance across all zone vet centers.
Closure Date:
15 The District Director ensures clinical staff consult with the vet center director, external clinical consultant, associate district director for counseling, or support VA medical facility mental health provider to include the suicide prevention coordinator following a client’s suicide risk assessment as required, and monitors compliance across all zone vet centers.
Closure Date:
16 The District Director, in collaboration with the support VA medical facility clinical or administrative liaisons, determines the reasons for noncompliance with staff participation on the mental health council for the Columbus, South Bend, and Toledo Vet Centers and takes actions as indicated to ensure compliance with Readjustment Counseling Service requirements.
Closure Date:
17 The District Director determines reasons for noncompliance with High Risk Suicide Flag SharePoint site requirements and the tracking of continuity of care for clients with a high risk-suicide flag or clients with an increased predictive risk for suicide at the Columbus, South Bend, and Toledo Vet Centers, takes action to ensure requirements are met, and monitors compliance.
Closure Date:
18 The District Director determines reasons a process for completing and tracking four hours of external clinical consultation per month did not occur at Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures vet center directors implement processes, and monitors compliance.
Closure Date:
19 The District Director determines reasons for noncompliance with staff supervision provided by vet center directors at the Cleveland, Columbus, South Bend, and Toledo Vet Centers, ensures staff supervision occurs as required, and monitors compliance.
Closure Date:
20 The District Director verifies and determines reasons for noncompliance with monthly RCSNet chart audits at the Cleveland, Columbus, South Bend, and Toledo Vet Centers; ensures chart audits are completed as required; and monitors compliance.
Closure Date:
21 The District Director determines reasons staff at the Cleveland, Columbus, South Bend, and Toledo Vet Centers did not complete required trainings, ensures all staff complete mandatory trainings, and monitors compliance.
Closure Date:
22 The District Director evaluates and determines reasons for noncompliance with tactile (braille) signage at the Toledo Vet Center and ensures all exit doors are compliant with Architectural Barriers Act Accessibility Standards.
Closure Date:
23 The District Director reviews reasons for noncompliance with maintaining a current and comprehensive emergency and crisis plan at the Cleveland, South Bend, and Toledo Vet Centers and ensures all emergency and crisis plans are comprehensive and updated as required.
Closure Date:
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| 21-02511-28 | Deficiencies in Suicide Risk Assessments, Continuity of Care, and Leadership at the South Bend Vet Center in Indiana | Hotline Healthcare Inspection | ||
1 The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors complete suicide risk assessments and assign risk levels based on client risk factors, reevaluate levels when risk factors change, and monitors staff’ compliance.
Closure Date:
2 The Midwest District 3 Director ensures the South Bend Vet Center Director and counselors consistently mitigate clients’ risk for suicide, as appropriate, by developing personalized safety plans, seeking clinical consultation, increasing client contact efforts, and completing crisis reports, and monitors compliance.
Closure Date:
3 The Midwest District 3 Director ensures that when clients are transferred from one counselor to another, relevant clinical information is communicated, applicable safety measures are in place, services are not disrupted, and when possible, a joint session with the outgoing and incoming counselor is held with the client.
Closure Date:
4 The Midwest District 3 Director reviews Client 1’s post-hospitalization care and the care coordination from the intern to a new counselor and determines if an adverse event disclosure is warranted.
Closure Date:
5 The Chief Readjustment Counseling Officer reviews VHA Directive 1004.08, Disclosure of Adverse Events to Patients, and develops a clear policy or protocol outlining the pathway for Readjustment Counseling Service leaders to comply with adverse event reporting, and monitors reporting compliance.
Closure Date:
6 The Chief Readjustment Counseling Officer ensures that prior to Readjustment Counseling Service accepting new interns, Readjustment Counseling Service leaders develop and implement a formalized intern orientation and training curriculum, as well as a clear supervisory oversight and safety protocol.
Closure Date:
7 The Midwest District 3 Director evaluates whether the Vet Center Director’s clinical practice warrants reporting to the state licensing board and takes action, as indicated.
Closure Date:
8 The Chief Readjustment Counseling Officer reviews VHA Directive 1100.18, Reporting and Responding to State Licensing Boards, and develops a clear policy or protocol outlining the pathway for Readjustment Counseling Service leaders to evaluate substandard care or ethical violations by licensed counselors, and when appropriate, reports concerns to state licensing boards.
Closure Date:
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| 22-01854-13 | Inspection of Information Security at the Tuscaloosa VA Medical Center in Alabama | Information Security Inspection | ||
1 Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.
Closure Date:
2 Ensure vulnerabilities are remediated within established time frames.
Closure Date:
3 Ensure all databases at the Tuscaloosa VA Medical Center are part of the periodic database scan process.
Closure Date:
4 Implement improved mechanisms to ensure system stewards are updating plans of actions and milestones for all known risks and weaknesses, including those identified during security control assessments.
Closure Date:
5 Ensure network segmentation controls are applied to all network segments with medical devices and special-purpose systems.
Closure Date:
6 Implement capabilities for generating database audit logs and forwarding audit events for review, analysis, and reporting.
Closure Date:
7 Ensure communication rooms with infrastructure equipment have adequate environmental controls.
8 Install uninterruptible power supplies in the communication rooms supporting infrastructure equipment.
Closure Date:
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15770