Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00603-86 | Healthcare Facility Inspection of the VA Hampton Healthcare System in Virginia | Healthcare Facility Inspection | ||
1 The OIG recommends the Director evaluates accessible parking spaces at the circle of the main entrance and ensures access aisles have visible pavement markings and remain available for use.
2 The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalks until completion.
3 The OIG recommends facility leaders improve doorway safety at the main entrance.
4 The OIG recommends the Director ensures staff have adequate hand hygiene supplies in or near soiled utility rooms that contain biohazardous materials.
5 The OIG recommends facility leaders ensure the facility policy for communication of test results and service-level workflows comply with VHA requirements, and staff implement processes to monitor patient notification of test results.
6 The OIG recommends facility leaders increase hiring efforts for the vacant social work positions in the Housing and Urban Development–Veterans Affairs Supportive Housing program, and in the interim, provide staff to support program enrollment.
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| 24-00823-68 | Care in the Community Inspection of South Central VA Health Care Network (VISN 16) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care oversight councils function according to their charters and meet the required number of times per fiscal year.
Closure Date:
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, reassess community care staffing needs and act as necessary.
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.
4 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility staff import all community care documents into the patient’s electronic health record within five business days of receipt.
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment after administratively closing consults that are not low risk.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community providers’ requests for additional services within three business days of receipt.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create and use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their community care appointments.
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff create the Community Care–Urgent Care Record note in the patient’s electronic health record when they receive medical documentation from the community provider.
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| 24-01143-44 | Veteran Self-Scheduling Process Needs Better Support, Stronger Controls, and Oversight | Review | ||
1 Evaluate its Veteran Self-Scheduling training and identify improvements if they are needed.
2 Make certain that staff who are involved in the Veteran Self-Scheduling process are trained on how to assess eligibility for the scheduling option, communicate key information to veterans on the option, and conduct appropriate consult follow-up procedures.
3 Ensure all guidance related to the Veteran Self-Scheduling process is clear, consistent, and disseminated to all VA medical facilities.
4 Establish a mechanism to effectively track and monitor each VA medical facility’s challenges with implementation of the Veteran Self-Scheduling process and then develop a plan to address reported issues.
5 Develop best practices and lessons learned for implementing the Veteran Self‑Scheduling process and disseminate them to all VA medical facilities.
6 Develop controls to ensure VA medical facility staff have the tools in place to identify instances of potential inappropriate processing or inappropriate use of Veteran Self-Scheduling consults.
7 Direct facilities to conduct routine reviews of Veteran Self-Scheduling consults to identify potential inappropriate processing or use of the Veteran Self-Scheduling option and notify VHA’s Office of Integrated Veteran Care of instances of inappropriate use.
8 Develop a plan to accurately assess whether the Veteran Self‑Scheduling process is meeting its intended goals.
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| 24-02106-80 | Review of Community Care Utilization, Delivery of Timely Care, and Provider Qualifications at the Montana VA Healthcare System in Fort Harrison, Fiscal Year 2022 | National Healthcare Review | ||
1 The Montana VA Healthcare System Director assesses the timeliness of appointment setting for direct and community care referrals and ensures facility staff establish appointments within required time frames.
2 The Montana VA Healthcare System Director assesses the timeliness of completion of community care appointments within 90 days of requested date and acts on identified opportunities for improvement.
Closure Date:
3 The Montana VA Healthcare System Director reviews consult management practices and ensures receiving staff document scheduled appointment dates for VA direct care referrals.
4 The Montana VA Healthcare System Director reviews appointment wait times and acts on identified opportunities for improvement.
5 The Montana VA Healthcare System Director ensures community care providers utilized by the system are designated as eligible in the Provider Profile Management System and acts on identified opportunities to improve the accuracy of eligibility designations.
Closure Date:
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| 24-00166-35 | Deficiencies in Managing Supply, Equipment, and Implant Inventory at the Michael E. DeBakey VA Medical Center in Houston, Texas | Review | ||
1 Ensure supervisors conduct monitoring activities, including periodic reviews of expendable and nonexpendable inventory and root cause analyses of identified discrepancies to strengthen controls over VA supplies.
Closure Date:
2 Establish routine monitoring for the accountable officer to verify the required use of barcode labels to track and identify supplies and equipment and report deficiencies for barcode replacement.
3 Address all unaccepted equipment and establish a requirement for custodial officers to routinely accept equipment in Maximo.
4 Implement a mechanism for the accountable officer to routinely monitor and ensure service‑line staff who conduct physical inventory are designated in writing by the custodial officers and receive the appropriate nonexpendable inventory training annually.
5 Require the accountable officer and supply chain staff to verify and update the information in the Maximo system and create procedures to ensure all nonexpendable equipment is received through the warehouse, recorded in Maximo, delivered in a timely manner to the requesting service, and accepted by the custodial officer.
6 Address the physical security issues identified and provide recurring training on proper physical security controls and procedures to individuals with authorized access to the primary inventory point and warehouse.
7 Ensure all biological and nonbiological implants are recorded in the approved inventory management system and are routinely reconciled with other systems used to manage implant expiration dates.
Closure Date:
8 Develop controls to ensure implant program staff identify and create local agreements for existing consignment implants and establish agreements for future consignment implants in accordance with national guidance.
Closure Date:
9 Officially designate a facility implant coordinator and establish a monitoring mechanism to ensure compliance with implant coordinator roles and responsibilities.
10 Update the local implant management policy to clarify roles and responsibilities and to train staff in these roles about their implant management responsibilities.
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| 24-00551-64 | Healthcare Facility Inspection of the VA Washington DC Healthcare System | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders improve crosswalk visibility and monitor pedestrian safety at the crosswalk between the patient parking garage and main entrance until completion.
2 The OIG recommends facility leaders ensure blanket warmer temperatures do not exceed 130 degrees Fahrenheit and implement a process to inform staff about proper use of the equipment.
3 The OIG recommends facility leaders implement actions to correct the electrical issue in the Emergency Department Main 2 area and mitigate the risk until it is resolved.
Closure Date:
4 The OIG recommends facility leaders reevaluate and improve their processes for identifying adverse events that warrant an institutional disclosure.
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| 24-02277-69 | Continued Sterile Processing Services Deficiencies and Facility Leaders’ Failures at the Carl Vinson VA Medical Center in Dublin, Georgia | Hotline Healthcare Inspection | ||
1 The Carl Vinson VA Medical Center Director ensures applicable staff, such as Sterile Processing Services staff and end users of reusable medical devices, comply with procedures regarding the identification of and disposition of nonconforming surgical instruments.
2 The Carl Vinson VA Medical Center Director confirms operating room staff completes training regarding the recognition of and procedures for nonconforming surgical instruments.
3 The VA Southeast Network Director establishes a comprehensive strategy to review patients who may have been affected by the approximately 800 nonconforming surgical instruments to evaluate whether harm occurred, the need for patients to undergo testing or treatment, and the appropriateness of disclosures.
Closure Date:
4 The VA Southeast Network Director evaluates whether administrative action is warranted for employees regarding Sterile Processing Services deficiencies at the Carl Vinson VA Medical Center, and takes action as appropriate.
5 The VA Southeast Network Director provides consultation and oversight to the Carl Vinson VA Medical Center’s Sterile Processing Services to ensure implementation of facility-level action plans and sustainability of identified outcomes.
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| 24-00592-60 | Healthcare Facility Inspection of the VA Dublin Healthcare System in Georgia | Healthcare Facility Inspection | ||
1 The OIG recommends that facility leaders review and correct any outdated navigational signage.
Closure Date:
2 The OIG recommends facility leaders define and assign roles and responsibilities to toxic exposure screening navigators and ensure program oversight.
3 The OIG recommends the Director ensures staff keep patient care areas safe and clean.
4 The OIG recommends the Director ensures biohazard storage areas display proper signage, have appropriate hand-washing supplies and equipment available, and do not contain housekeeping supplies.
5 The OIG recommends the Associate Director ensures staff identify one or more facility environment of care trends and establish a performance improvement plan, including outcome measures, to address them.
6 The OIG recommends that facility leaders continue to develop and implement administrative processes to ensure ordering providers promptly communicate and document test results.
7 The OIG recommends that facility leaders ensure staff maintain and reference current VHA requirements and update facility-level policies and standard operating procedures to comply with them.
8 The OIG recommends facility leaders ensure homeless program staff have access to appropriate vehicles to conduct their work.
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| 24-00594-61 | Healthcare Facility Inspection of the VA Central Western Massachusetts Healthcare System in Leeds | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders assess storage locations that are outside of standard supply rooms and implement a process to ensure staff remove expired supplies.
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| 22-03076-65 | Ensuring Grantee Compliance with Veteran Care and Safety Requirements in Transitional Housing: Lessons Learned from San Diego | Administrative Investigation | ||
1 Clarify policies, guidance, and/or training on when admissions holds, removal of veterans from grantee facilities, and the withholding or suspension of per diem payments are appropriate and required.
2 Clarify policies, guidance, and/or training on how facility staff determine whether corrective actions for an identified problem related to a grantee should be required or suggested, including what factors to consider, who makes the final determination, and whether and how the determination is reviewed by others.
3 Implement a mechanism designed to reasonably ensure that VA oversight staff take appropriate enforcement measures to address persistent or recurring deficiencies by a Grant and Per Diem grantee that pose risks to veteran care and safety.
4 Ensure grant agreements require the grantee to promptly disclose to VA any adverse health or safety conditions occurring at any facility where VA-funded participants are receiving service, including the occurrence of sentinel events affecting non-VA-funded participants on the grantee’s premises and any adverse health or safety inspection results or similar findings made concerning the grantee’s premises or operations by any non-VA oversight entity, such as a federal, state, county, or local regulator.
5 Ensure Grant and Per Diem participants residing at the Veterans Village of San Diego (VVSD) who are eligible for clinical drug treatment receive appropriate support to obtain those services despite the closure of VVSD’s clinical treatment housing model.
Closure Date:
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14921