Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-00272-283 | Comprehensive Healthcare Inspection of the West Palm Beach VA Medical Center in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all core members consistently attend Surgical Work Group meetings.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that 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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| 20-03407-253 | VA’s Management of Land Use under the West Los Angeles Leasing Act of 2016: Five-Year Report | Audit | ||
1 Implement a plan that brings the five new noncompliant land use agreements into compliance with the West Los Angeles Leasing Act of 2016, the draft master plan, and other federal laws, allowing reasonable time to correct deficiencies noted in this report.
2 Ensure VA’s capital asset inventory accurately reflects all land use agreements lasting six months or longer on the West Los Angeles campus.
Closure Date:
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| 21-00553-285 | Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA Illiana Health Care System in Danville, Illinois | Hotline Healthcare Inspection | ||
1 The VA Great Lakes Health Care System Director evaluates whether administrative action is warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at the VA Illiana Health Care System, and takes action, as appropriate.
Closure Date:
2 The VA Illiana Health Care System Director ensures the plan to monitor and track face mask wearing by staff at the community living center adheres to current Centers for Disease Control and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as warranted.
Closure Date:
3 The VA Illiana Health Care System Director confirms that all community living center staff identified as requiring respiratory protection are fit tested, trained, and have ready access to respiratory devices.
Closure Date:
4 The VA Illiana Health Care System Director ensures a plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding staff with known community exposure to COVID-19, and monitors for compliance.
Closure Date:
5 The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding community living center residents with known exposure to individuals diagnosed with COVID-19, and monitors compliance.
Closure Date:
6 The VA Illiana Health Care System Director ensures operability and use of the bed management system for tracking completion of room cleaning.
Closure Date:
7 The VA Illiana Health Care System Director oversees the completion and implementation of a policy for administering aerosol-generating procedures during the COVID-19 pandemic that adheres to Centers for Disease Control and Prevention guidance, and monitors compliance.
Closure Date:
8 The VA Illiana Health Care System Director evaluates the organizational approach for notifying managers of updated Veterans Health Administration policies and guidance for monitoring actions taken to ensure compliance with new requirements.
Closure Date:
9 The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans Health Administration guidance related to community living center practices, including group activities, disseminated during emergent events such as a pandemic and maintains oversight of community living center leaders’ implementation of such guidance.
Closure Date:
10 The VA Illiana Health Care System Director directs community living center leaders to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing.
Closure Date:
11 The VA Illiana Health Care System Director evaluates the community living center standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure that it provides guidance with specific actions for staff to take when a resident tests positive for COVID-19.
Closure Date:
12 The VA Illiana Health Care System Director verifies that COVID-19 testing for community living center residents and staff occurs as required for both routine surveillance and in response to confirmed cases of COVID-19.
Closure Date:
13 The VA Illiana Health Care System Director confirms that the community living center COVID-19 standard operating procedure clearly communicates the process, including roles and responsibilities, for notification of a resident’s change in condition or room assignment and communicates the plan to all community living staff.
Closure Date:
14 The VA Illiana Health Care System Director executes a process to ensure that the facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the community living center, and when identified, creates a plan to mitigate and manage risk.
Closure Date:
15 The VA Illiana Health Care System Director directs those conducting the facility’s after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.
Closure Date:
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| 21-01304-275 | Care Concerns and the Impact of COVID-19 on a Patient at the Fayetteville VA Coastal Health Care System in North Carolina | Hotline Healthcare Inspection | ||
1 The Fayetteville VA Coastal Health Care System Director ensures that dietitians comply with conducting and documenting comprehensive nutrition assessments, including patients’ weight measurements, changes to nutrition diagnosis, chewing and swallowing abilities, and calorie and protein requirements.
Closure Date:
2 The Fayetteville VA Coastal Health Care System Director ensures there is consistent communication and coordination of care between the Patient Aligned Care Team registered nurses and the primary care providers.
Closure Date:
3 The Fayetteville VA Coastal Health Care System Director provides guidance on care coordination between outpatient dietitians and primary care providers when a higher level of nutrition intervention is required.
Closure Date:
4 The Fayetteville VA Coastal Health Care System Director monitors that follow-up appointments for dietitians are scheduled as ordered.
Closure Date:
5 The Fayetteville VA Coastal Health Care System Director ensures that non-VA dental appointments are scheduled within recommended time frames by the Community Care program scheduling staff and monitors compliance.
Closure Date:
6 The Fayetteville VA Coastal Health Care System Director evaluates the COVID-19 scheduling practices and the impact of telephone appointments on the patient’s care.
Closure Date:
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| 20-01910-244 | Contracting Officer Warranting Program Meets Federal Requirements but Could Be Strengthened | Review | ||
1 The OIG recommended the executive director of the Office of Acquisition and Logistics assess the warrant justification template and determine whether additional information and guidance should be required.
Closure Date:
2 The OIG recommended the executive director of the Office of Acquisition and Logistics determine whether any additional formalized procedures to monitor contracting officer workload should be implemented and required throughout VA.
Closure Date:
3 The OIG recommended the executive director of the Office of Acquisition and Logistics identify updates to warrant program policies that can increase the consistency of standards and practices across VA to promote fairness and stringency of warrant requirements.
Closure Date:
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| 21-00261-266 | Comprehensive Healthcare Inspection of the VA Boston Healthcare System in Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures disclosure of adverse events that require an institutional disclosure.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Peer Review Committee completes a final review of each case within 120 calendar days from the determination that a peer review is needed or approves a written extension request.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that emergency department and urgent care center staff screen patients for suicide risk using the Columbia-Suicide Severity Rating Scale.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and establishes a written policy to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
5 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure staff monitor and evaluate patient transfers.
Closure Date:
6 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure appropriately privileged providers complete the VA Inter-Facility Transfer Form or a facility-defined equivalent note, that includes all required elements, in the electronic health record prior to patient transfers.
Closure Date:
7 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and make certain that staff send patients’ active medication lists to the receiving facility during inter-facility transfers.
Closure Date:
8 The Chief of Staff and Nurse Executive evaluate and determine any additional reasons for noncompliance and ensure that nurse-to-nurse communication occurs as part of the inter-facility transfer process.
Closure Date:
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| 21-00269-268 | Comprehensive Healthcare Inspection of the North Florida/South Georgia Veterans Health System in Gainesville, Florida | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Staff consistently attends Surgical Steering Committee 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 the referring provider identifies the receiving physician in the 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 make certain that referring providers send patients’ active medication lists to receiving facilities.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures that staff complete the assigned prevention and management of disruptive behavior training or required training for transitory, part-time, and intermittent clinical staff.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures that members of the Employee Threat Assessment Team complete the required the training.
Closure Date:
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| 21-00257-252 | Comprehensive Healthcare Inspection of the VA Maine Healthcare System in Augusta | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the acting Systems Redesign and Improvement Coordinator participates on the Quality, Safety, Value Board to review program data and information.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Peer Review Committee submits quarterly summaries of peer review data for review by the Clinical Executive Board.
Closure Date:
3 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and the Chief of Staff attends the meetings.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and maintains a current policy to ensure the safe, appropriate, orderly, and timely transfer of patients
Closure Date:
5 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain the Interfacility Transfer Committee monitors and evaluates patient transfers.
Closure Date:
6 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that providers document patients’ informed consent prior to inter-facility transfers.
Closure Date:
7 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure that appropriately privileged providers complete or co-sign the VA Inter-Facility Transfer Form or equivalent note prior to patient transfers.
Closure Date:
8 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and make certain that nurse-to-nurse communication between the sending and receiving facility occurs during the inter-facility transfer process.
Closure Date:
9 The Chief of Staff and Associate Director for Patient and Nursing Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification of an Order of Behavioral Restriction, with information regarding the right to appeal, in the Disruptive Behavior Reporting System.
Closure Date:
11 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff 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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| 21-00271-258 | Deficiencies in Mental Health Care and Facility Response to a Patient’s Suicide, VA Portland Health Care System in Oregon and Treatment Program Referral Processes at the VA Palo Alto Health Care System in California | Hotline Healthcare Inspection | ||
1 The VA Portland Health Care System Director establishes a mental health treatment coordinator policy, consistent with Veterans Health Administration policy, and includes procedures for mental health treatment coordinator assignment.
Closure Date:
2 The VA Portland Health Care System Director develops procedures consistent with Veterans Health Administration suicide behavior and overdose report staff-specific guidance and monitors for compliance.
Closure Date:
3 The Under Secretary for Health aligns policy and training to reflect staff-specific guidance and requirements for suicide behavior and overdose report procedures and disseminates updated information to medical center leaders.
Closure Date:
4 The VA Portland Health Care System Director ensures completion of behavioral health autopsy reports within the Veterans Health Administration required time frame.
Closure Date:
5 The Under Secretary for Health clarifies timeframe expectations for notification of Residential Rehabilitation Treatment Programs admission decisions to referring providers and patients, and takes action as warranted.
Closure Date:
6 The VA Palo Alto Health Care System Director ensures that Residential Rehabilitation Treatment Program procedures are consistent with Veterans Health Administration requirements, including screening and admission decision timeliness, communication of treatment recommendations to referring provider and patient, and acceptance of patient self-referrals.
Closure Date:
7 The VA Palo Alto Health Care System Director makes certain that the VA Palo Alto Health Care System Policy 11K-18-04, Assistance Dog Policy, is consistent with Veterans Health Administration policy.
Closure Date:
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| 20-01802-234 | Better Oversight of Prosthetic Spending Needed to Reduce Unreasonable Prices Paid to Vendors | Audit | ||
1 Coordinate with appropriate officials, including the VA Office of General Counsel, and determine if 38 U.S.C. § 1703(i) and other reimbursement practices cited in this report apply to the reimbursement rates medical facilities should pay for prosthetic and orthotic items provided by vendors. If they do apply, develop and issue guidance requiring medical facilities to adhere to them; if they do not apply, develop and issue guidance on steps medical facilities need to take to ensure they purchase prosthetic and orthotic items at reasonable prices.
Closure Date:
2 Develop and implement effective procedures to monitor prosthetic spending to make sure medical facilities reimburse vendors at reasonable prices for all prosthetic and orthotic items in accordance with updated pricing policies and processes.
3 Coordinate with appropriate officials such as the Prosthetic and Sensory Aids Service executive director and the executive director, Rehabilitation and Prosthetics Service, to establish a formal oversight structure that defines the roles and responsibilities of those charged with providing oversight of the prosthetics program, rescind handbooks that reflect an outdated oversight structure, and communicate updated oversight expectations to the Veterans Integrated Service Networks to promote consistent program oversight.
Closure Date:
4 Resolve National Prosthetics Patient Database limitations and establish requirements to routinely monitor medical facilities’ input of data to improve accuracy.
Closure Date:
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14957