Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-01979-199 | Challenges for Military Sexual Trauma Coordinators and Culture of Safety Considerations | National Healthcare Review | ||
1 The Under Secretary for Health evaluates the sufficiency of current guidance and operational status regarding protected administrative time, administrative staff support, and funding for outreach, education, and special project resources, with consideration of the Military Sexual Trauma Coordinators’ responsibilities, and takes action as warranted.
Closure Date:
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| 20-01262-191 | Comprehensive Healthcare Inspection of the Mann-Grandstaff VA Medical Center in Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director determines reasons for noncompliance and ensures that the Protected Peer Review Committee completes final reviews within 120 calendar days or has a written extension request approved by the Director.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures root cause analyses’ corresponding actions and outcome measures show sustained improvement.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in practitioners’ profiles.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic, with the veterans’ preference documented, within the required time frame.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete suicide safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five outreach activities each month.
Closure Date:
7 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual refresher training.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that written processes and procedures are in place for 24 hours per day, 7 days per week gynecological care.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned to and consistently attend Women Veterans Health Committee meetings.
Closure Date:
10 The Medical Center Director evaluates and determines the reasons for noncompliance and makes certain the Women Veterans Program Manager collects and tracks data for follow-up of abnormal mammogram and cervical cytology reports and the timeliness of breast and cervical cancer treatment.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
Closure Date:
12 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
13 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment complete competency assessments.
Closure Date:
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| 20-01254-185 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 20: VA Northwest Health Network in Vancouver, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Officer determines the 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 ensures that the Veterans Integrated Service Network Sterile Processing Services Lead provides network-led facility reusable medical equipment inspection results to executive leaders.
Closure Date:
3 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that Veterans Integrated Service Network staff post inspection results to the reusable medical equipment SharePoint site within the required time frame.
Closure Date:
4 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the Veterans Integrated Service Network Sterile Processing Services Lead oversees facility development of corrective action plans within the required time frame and tracks action items until closure.
Closure Date:
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| 20-02828-174 | Opportunities Exist to Improve Management of Noninstitutional Care through the Veteran-Directed Care Program | Audit | ||
1 The OIG recommended the under secretary for health establish a process to ensure program personnel document veterans’ quarterly monitoring in their electronic health records, such as by using a standardized template.
Closure Date:
2 The OIG recommended the under secretary for health etablish a process to ensure the provider agency list in the Electronic Claims Adjudication Management System is updated as new provider agencies are added to the program.
Closure Date:
3 The OIG recommended the under secretary for health etablish a process to ensure proper pricing in the Electronic Claims Adjudication Management System when paying program claims.
Closure Date:
4 The OIG recommended the under secretary for health update program guidance on claims submission and processing to make sure provider agencies are aware of the need to include all required information when submitting program claims.
Closure Date:
5 The OIG recommended the under secretary for health establish guidance to include processes that medical facilities must follow to determine if veterans are receiving the same personal care services through the Veteran Directed Care program and the Program of Comprehensive Assistance for Family Caregivers, and how to address these situations, as appropriate.
Closure Date:
6 The OIG recommended the under secretary for health ensure program personnel determine if veterans enrolled in both the Veteran Directed Care and the Program of Comprehensive Assistance for Family Caregivers are receiving the same personal care services and take action, as appropriate.
Closure Date:
7 The OIG recommended the under secretary for health establish procedures to identify program staffing needs and define program personnel’s roles and responsibilities at the national, network, and local levels.
Closure Date:
8 The OIG recommended the under secretary for health update procedures for tracking and reporting demand for and use of program services and use these data to inform yearly cost estimates for the program.
Closure Date:
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| 20-02368-202 | Deficiencies in Mental Health Care Coordination and Administrative Processes for a Patient Who Died by Suicide, Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Hotline Healthcare Inspection | ||
1 The Ralph H. Johnson VA Medical Center Director ensures adherence to Veterans Health Administration policy in the renewal review of patients’ high risk for suicide patient record flag, and monitors compliance.
Closure Date:
2 The Ralph H. Johnson VA Medical Center Director evaluates compliance with Mental Health Treatment Coordinator assignment requirements, and takes action to address identified deficiencies as indicated.
Closure Date:
3 The Ralph H. Johnson VA Medical Center Director reviews the patient’s care to include staff’s adherence to “Recovery Engagement and Coordination for Health–Veterans Enhanced Treatment” program requirements and appropriate outreach, consults with Human Resources and General Counsel Offices, and takes action as warranted.
Closure Date:
4 The Ralph H. Johnson VA Medical Center Director ensures that Mental Health Service staff complete patients’ suicide risk screenings and assessments as required by the Veterans Health Administration, and monitors compliance.
Closure Date:
5 The Ralph H. Johnson VA Medical Center Director evaluates procedures for non-clinical staff to notify appropriate leaders of patient deaths by suicide, and takes action as needed.
Closure Date:
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| 20-03763-207 | Deficiencies in the Management of a Patient’s Reported Intimate Partner Violence, Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Hotline Healthcare Inspection | ||
1 The Ralph H. Johnson VA Medical Center Director ensures mental health staff consult with the Intimate Partner Violence Assistance Program and safety plan, as warranted to address Intimate Partner Violence.
Closure Date:
2 The Ralph H. Johnson VA Medical Center Director ensures Inpatient Mental Health Unit resident physicians complete timely clinical documentation in accordance with Ralph H. Johnson VA Medical Center Policy.
Closure Date:
3 The Ralph H. Johnson VA Medical Center Director makes certain staff consult with the Office of General Counsel to determine reporting requirements of Intimate Partner Violence, as appropriate.
Closure Date:
4 The Under Secretary for Health establishes clear guidance related to Intimate Partner Violence training requirements.
Closure Date:
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| 21-00519-192 | Review of VA’s Compliance with the Payment Integrity Information Act for Fiscal Year 2020 | Review | ||
1 The OIG recommended the under secretary for benefits ensure the Pension Program meets its reduction target.
Closure Date:
2 The OIG recommended the under secretary for health ensure the Purchased Long-Term Services and Supports Program meets its reduction target.
Closure Date:
3 The OIG recommended the under secretary for health reduce improper payments to below 10 percent for Beneficiary Travel; Communications, Utilities, and Other Rent; Medical Care Contracts and Agreements; Purchased Long Term Services and Supports; and VA Community Care Programs and activities.
Closure Date:
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| 20-01259-196 | Comprehensive Healthcare Inspection of the Roseburg VA Health Care System in Oregon | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager or designee includes all required review elements in root cause analyses.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs evaluate practitioners based on service-specific criteria.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff evaluates and determines the reasons for noncompliance and makes certain the Executive Council of Medical Staff reviews and evaluates licensed independent practitioners’ reprivileging requests and documents the review in the meeting minutes.
Closure Date:
5 The System Director evaluates and determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Suicide Prevention Coordinator provides in-person Operation S.A.V.E. training at new employee orientation.
Closure Date:
7 The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations.
Closure Date:
8 The System Director evaluates and determines the reasons for noncompliance and ensures providers complete and document goals of care conversations within the required time frame.
Closure Date:
9 The System Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
Closure Date:
10 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
Closure Date:
11 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures are reviewed at least every three years and updated when there is a change in process or manufacturer’s instructions for use.
Closure Date:
12 The Associate Director for Patient Care Services evaluates and determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
13 The Associate Director of Patient Care Services determines the reasons for noncompliance and ensures that all employees who reprocess reusable medical equipment receive monthly continuing education.
Closure Date:
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| 21-00657-197 | Failures in Care Coordination and Reviewing a Patient’s Death at the VA Salt Lake City Healthcare System in Utah | Hotline Healthcare Inspection | ||
1 The VA Salt Lake City Healthcare System Director conducts a clinical review of the care provided to the patient on Monday (day 7), by Idaho Falls Community-Based Outpatient Clinic staff, and takes action as warranted.
Closure Date:
2 The VA Salt Lake City Healthcare System Director reviews the processes involved in conducting root cause analyses to ensure that final reports contain complete and accurate information.
Closure Date:
3 The VA Salt Lake City Healthcare System Director determines if an institutional disclosure is warranted following the completion of the clinical review of this patient’s care and takes action as necessary.
Closure Date:
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| 20-01261-194 | Comprehensive Healthcare Inspection of the VA Puget Sound Health Care System in Seattle, Washington | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines the reasons for noncompliance and ensures that improvement actions recommended by the Executive Leadership Council are fully implemented and monitored.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that final peer reviews are completed within 120 calendar days or have a written extension request approved by the Director.
Closure Date:
3 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee completes at least eight patient safety analysis processes each fiscal year.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee includes an analysis of underlying systems in all root cause analyses.
Closure Date:
5 The System Director evaluates and determines any additional reasons for noncompliance and ensures that improvement actions identified from root cause analyses are implemented.
Closure Date:
6 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Patient Safety Manager or designee submits each root cause analysis to the National Center for Patient Safety within the required time frame.
Closure Date:
7 The System Director evaluates and determines reasons for noncompliance and ensures the Patient Safety Manager or designee provides an annual patient safety report to healthcare system leaders.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document focused professional practice evaluation criteria in practitioner profiles.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that licensed independent practitioners’ professional practice evaluations are completed by providers with similar training and privileges.
Closure Date:
10 The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that service chiefs’ reprivileging decisions are based on ongoing professional practice evaluation data.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Credentialing and Privileging Committee meeting minutes consistently reflect the review of professional practice evaluation results and the rationale for privileging recommendations.
Closure Date:
12 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven business days of licensed healthcare professionals’ departure from the healthcare system.
Closure Date:
13 The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of substance abuse and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing for patients prior to initiating long-term opioid therapy.
Closure Date:
15 The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
16 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up evaluations of patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and effectiveness of the interventions.
Closure Date:
17 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete goals of care conversations and life-sustaining treatment decisions progress notes.
Closure Date:
18 The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains the required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
Closure Date:
19 The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
20 The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete competency assessments.
Closure Date:
21 The Deputy Director of Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees receive monthly continuing education.
Closure Date:
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14957