Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 21-01509-264 | Comprehensive Healthcare Inspection Summary Report: Evaluation of High-Risk Processes 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, makes certain that facility staff use standard operating procedures that align with manufacturers’ guidelines when reprocessing colonoscopes.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures Sterile Processing Services chiefs report annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that Sterile Processing Services chiefs develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
Closure Date:
4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures Sterile Processing Services staff properly store high-level disinfected endoscopes.
Closure Date:
5 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
6 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that Sterile Processing Services staff complete competency assessments for reprocessing reusable medical equipment.
Closure Date:
7 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 21-01677-259 | Facility Leaders’ Response to Level 2 and Level 3 Pathology Reading Errors at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health clarifies the extent and content of documentation that should be included when circumstances require that a clinical disclosure be entered into the electronic health record.
Closure Date:
2 The Under Secretary for Health evaluates whether there should be a process for clinical provider(s) to communicate back to the Clinical Review Team when changes in patient health status indicate the need for consideration of institutional disclosures, and takes action as warranted.
Closure Date:
3 The Veterans Health Care System of the Ozarks Director implements a plan for completion of amended pathology reports for cases identified with level 2 pathology reading errors that is consistent with VHA Handbook 1106.01.
Closure Date:
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| 21-00233-257 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 19: VA Rocky Mountain Network in Glendale, Colorado | Comprehensive Healthcare Inspection Program | ||
1 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that Veterans Integrated Service Network peer review summary data are collected, analyzed, and acted on, as appropriate.
Closure Date:
2 The Chief Medical Officer determines the reason 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:
3 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager provides quarterly program updates to Veterans Integrated Service Network leaders.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager completes staff education gap assessments related to women’s health and develops educational programs and resources where gaps are identified.
Closure Date:
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| 20-00971-235 | Financial Efficiency Review of the Southeast Louisiana Veterans Health Care System in New Orleans | Financial Inspection | ||
1 The OIG recommended the director of the Southeast Louisiana Veterans Health Care System develop a plan to work with the prime vendor to address having adequate stock from the facility’s formulary list in its warehouse to provide supplies when ordered.
Closure Date:
2 The OIG recommended the director of the Southeast Louisiana Veterans Health Care System ensure logistics staff and the contracting officer’s representative use the tools available to inform the Medical Supplies Program Office and Strategic Acquisition Center of prime vendor performance issues.
Closure Date:
3 The OIG recommended the director of the Southeast Louisiana Veterans Health Care System and the director of contracting for South Central VA Health Care Network Contracting Office 16
ensure approving officials and cardholders review their purchases and make sure strategic sourcing is used when it is in the best interest of the government.
Closure Date:
4 The OIG recommended the director of the Southeast Louisiana Veterans Health Care System in coordination with the network purchase card program manager, require purchase cardholders to submit ratification requests to the director of contracting for Network Contracting Office 16 for any unauthorized commitments identified.
Closure Date:
5 The OIG recommended the director of contracting for South Central VA Health Care Network Contracting Office 16 ensure quarterly audits of the purchase card program are completed as required by the Veterans Health Administration standard operating procedure, “Internal Audits—Purchase Cards and Convenience Checks.”
Closure Date:
6 The OIG recommended the director of the Southeast Louisiana Veterans Health Care System ensure that the facility meets the Veterans Health Administration’s recommended inventory turnover rate of 12 per year, established by the National Pharmacy Benefits Management program office.
Closure Date:
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| 21-00245-256 | Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center in Wyoming | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that 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 medical center staff monitor and evaluate inter-facility patient transfers.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that providers complete all elements of the VA Inter-Facility Transfer Form or a facility-defined equivalent note prior to patient transfers.
Closure Date:
4 The Medical Center Director determines the reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
Closure Date:
5 The Medical Center Director determines the reasons for noncompliance and makes certain that the medical center has a current policy for reporting and tracking disruptive behavior.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Disruptive Behavior Committee documents patient notification of an Order of Behavioral Restriction and right to appeal in the Disruptive Behavior Reporting System.
Closure Date:
7 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that 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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| 20-02907-254 | Deficiencies in Administrative Actions for a Patient’s Inpatient Mental Health Unit and Community Living Center Admissions at the Tuscaloosa VA Medical Center in Alabama | Hotline Healthcare Inspection | ||
1 The Tuscaloosa VA Medical Center Director reviews informed treatment consent processes for the Inpatient Mental Health Unit and Community Living Center, confirms staff understanding of required processes, and monitors compliance.
Closure Date:
2 The Tuscaloosa VA Medical Center Director ensures decision-making capacity evaluation completion and documentation, as required by Veterans Health Administration policy, and monitors compliance.
Closure Date:
3 The Tuscaloosa VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of Alabama commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
Closure Date:
4 The Tuscaloosa VA Medical Center Director ensures adherence to Tuscaloosa VA Medical Center policies regarding against medical advice discharge procedures, and monitors compliance.
Closure Date:
5 The Tuscaloosa VA Medical Center Director consults with VA National Center for Ethics in Healthcare and reconsults the Office of General Counsel as needed to evaluate the appropriateness of the patient’s assigned surrogate decision-maker, and takes action as warranted.
Closure Date:
6 The Tuscaloosa VA Medical Center Director ensures staff completion of required patient advocate reporting and tracking processes, and monitors compliance.
Closure Date:
7 The Tuscaloosa VA Medical Center Director evaluates the Community Living Center staff’s management of the patient’s correspondence request, including the Integrated Ethics consultation, and takes action as warranted.
Closure Date:
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| 21-00258-230 | Comprehensive Healthcare Inspection of the White River Junction VA Medical Center in Vermont | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly.
Closure Date:
2 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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| 21-00262-247 | Comprehensive Healthcare Inspection of the Manchester VA Medical Center in New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Surgical Work Group meetings.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that transferring providers identify the receiving provider on the VA Inter-Facility Transfer Form or facility-defined equivalent note.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff send the patient’s active medication list to the receiving facility during the inter-facility transfer.
Closure Date:
5 The Associate Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures nurse-to-nurse communication occurs between the sending and receiving facility.
Closure Date:
6 The Chief of Staff and Associate Director for 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 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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| 21-00263-246 | Comprehensive Healthcare Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines reasons for noncompliance and makes certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
2 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff document decisions to implement an Order of Behavioral Restriction and patient notifications in the Disruptive Behavior Reporting System.
Closure Date:
4 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:
5 The System Director evaluates and determines reasons for noncompliance and ensures the chair and members of the Employee Threat Assessment Team complete the required training.
Closure Date:
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| 20-00395-224 | Excess Purchase of Surgical Supplies and Improper Purchase Card Transactions at the New Orleans VA Medical Center in Louisiana | Review | ||
1 The OIG recommended the Southeast Louisiana Veterans Health Care System director account for the disposition of just over $125,000 in unaccounted for supplies in accordance with VA policies.
Closure Date:
2 The OIG recommended the Southeast Louisiana Veterans Health Care System director determine if any administrative action should be taken on just over $675,000 in unaccounted-for supplies listed in the report of survey.
Closure Date:
3 The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure Federal Acquisition Regulation violations that resulted when purchase cards were used to acquire the approximately $1.9 million of supplies are reported to the Financial Services Center, and appropriate remedies, discipline, or penalties are taken in accordance with VA Financial Policy, Volume XVI.
Closure Date:
4 The OIG recommended the Southeast Louisiana Veterans Health Care System director request the Veterans Health Administration’s head of contract activity ratify the approximately $1.9 million of identified split purchases.
Closure Date:
5 The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure appropriate medical center employees coordinate with and obtain guidance from National Purchase Card Program staff when they are uncertain if they are properly using government purchase cards.
Closure Date:
6 The OIG recommended the Southeast Louisiana Veterans Health Care System director ensure leased operating room equipment is returned to the contractor as soon as possible if there are no plans to use that operating room for at least one year.
Closure Date:
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14957