Recommendations
2080
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 20-03465-243 | Failure to Locate Missing Veteran Found Dead at a Facility on the Bedford VA Hospital Campus | Administrative Investigation | ||
1 The under secretary for health makes certain that policies and procedures are developed to require VA police, and other VHA staff as appropriate, to conduct searches for all persons who are reported missing on medical center campuses.
2 The executive director of the Office of Security and Law Enforcement updates VA Handbook 0730 with revisions clarifying VA police responsibilities with respect to searching for persons who are reported missing on VA property.
Closure Date:
3 The assistant under secretary for health for operations, in consultation with the VA chief security officer, requires VA police chiefs at medical centers to obtain approval from the facility associate director or the medical center director prior to excluding a building or area of the medical center’s campus from regular patrols, and, if the building or area is subject to an enhanced-use lease, confirms with the Office of Enterprise Asset Management and the Office of General Counsel that the exclusion is not in conflict with the terms of the lease.
4 For all medical centers that have property subject to enhanced-use leases, the assistant under secretary for health for operations, in consultation with the VA chief security officer, requires the medical center director or the director’s designee to meet with the assigned oversight monitor at the Office of Asset Enterprise Management, the designated local site monitor, and a representative of the Office of General Counsel at least annually—or sooner if there is a change of lease terms or facility leadership—to discuss the terms of the enhanced-use leases and the lessee’s and VA’s responsibilities with respect to the leased properties.
5 The executive director of the Office of Asset Enterprise Management includes a copy of the lease and VA Handbook 7454 with the designation memorandum sent to newly appointed lease site monitors.
Closure Date:
6 The executive director of the Office of Asset Enterprise Management, in conjunction with the Office of General Counsel, reviews all active enhanced-use leases to determine whether any involve portions of buildings also occupied by VA, and, if so, whether they are clear regarding the maintenance and security obligations.
Closure Date:
7 The executive director of the Office of Asset Enterprise Management modifies its existing Annual Oversight Compliance Certificate policies to include a review of VA’s performance with respect to any services VA is required to provide under the terms of enhanced-use leases.
Closure Date:
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| 21-00260-232 | Comprehensive Healthcare Inspection of the Edith Nourse Rogers Memorial Veterans’ Hospital in Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff complete mandatory suicide safety plan training prior to developing suicide safety plans.
Closure Date:
2 The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that the referring physician completes all required elements of the VA Inter-Facility Transfer Form or facility-defined equivalent prior to patient transfer.
Closure Date:
3 The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure that staff send all pertinent medical records to the receiving facility during inter-facility transfers.
Closure Date:
4 The Associate Director Nursing and Patient Care Services determines the reasons for noncompliance and makes certain that nurse-to-nurse communication occurs between the sending and receiving facility.
Closure Date:
5 The Chief of Staff and Associate Director Nursing and Patient Care Services evaluate and determine any additional reasons for noncompliance and make certain that required members attend Disruptive Behavior Committee meetings.
Closure Date:
6 The Hospital 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:
7 The Hospital Director evaluates and determines any additional reasons for noncompliance and ensures Employee Threat Assessment Team members complete required training.
Closure Date:
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| 21-00251-212 | Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System in Muskogee | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff conduct institutional disclosures for all sentinel events.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and designates a systems redesign and improvement coordinator.
Closure Date:
3 The System Director evaluates and determines any additional reasons for noncompliance and ensures that required members regularly attend Surgical Work Group meetings.
Closure Date:
4 4. The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the transferring physician records all required elements on the Inter-Facility Transfer Form or facility-defined equivalent note prior to patient transfers.
Closure Date:
5 The Chief of Staff determines the reasons for noncompliance and ensures that transferring providers send patients’ active medication lists to receiving facilities during inter-facility transfers.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that all required members attend Disruptive Behavior Committee meetings.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Disruptive Behavior Committee documents patient notification for an Order of Behavioral Restriction in the Disruptive Behavior Reporting System.
Closure Date:
8 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that Employee Threat Assessment Team members complete the required training.
Closure Date:
9 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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| 20-03938-208 | Blue Water Navy Outreach Requirements Were Met, but Claims Processing and Procedures Could Improve | Review | ||
1 The OIG recommendated the under secretary for benefits develop and distribute procedures for when the ship locator tool provides results based on deck log coordinates for unlikely locations of herbicide exposure.
Closure Date:
2 The OIG recommended the under secretary for benefits determine and execute additional actions to ensure employees processing Blue Water Navy claims understand how to accurately evaluate and decide herbicide-related medical conditions.
Closure Date:
3 The OIG recommended the undersecretary for benefits implement a plan for centralized regional offices to conduct local reviews on the accuracy of rating decisions involving herbicide-related medical conditions that will mitigate error trends identified.
Closure Date:
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| 21-00253-239 | Comprehensive Healthcare Inspection of the Oklahoma City VA Health Care System in Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 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:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete suicide safety plan training prior to developing suicide prevention safety plans.
Closure Date:
3 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine additional reasons for noncompliance and make certain that all transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
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 required members attend Disruptive Behavior Committee meetings.
Closure Date:
5 The System 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 area.
Closure Date:
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15042