Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-08267-147 | Contracted Residence Programs Need Stronger Monitoring to Ensure Veterans Experiencing Homelessness Receive Services | Audit | ||
1 Establish control mechanisms at the Veterans Integrated Service Network and Contracted Residential Services program levels to ensure Contracted Residential Services staff at medical facilities comply with Veterans Health Administration Handbook 1162.09 requirements for monitoring and documentation.
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2 Direct Network Contracting Offices to establish controls to verify contracting officers meet with contracting officer’s representatives on at least a quarterly basis to evaluate contractor performance and document the meetings.
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3 Direct Network Contracting Offices for all Contracted Residential Services contracts to ensure contracting officers include quality assurance surveillance plans and promptly issue letters of delegation to staff who have been nominated to be contracting officer’s representatives.
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4 Update Veterans Health Administration Handbook 1162.09 to incorporate unannounced site visits to the extent possible during annual inspections and quarterly evaluations.
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5 Update Veterans Health Administration Handbook 1162.09 to include guidance on paying for veteran absences and make certain these requirements are reflected in contracts and surveillance plans.
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| 20-04341-182 | Audiology Leaders’ Deficiencies Responding to Poor Care and Monitoring Performance at the Eastern Oklahoma VA Health Care System in Muskogee | Hotline Healthcare Inspection | ||
1 The Eastern Oklahoma VA Health Care System Director confirms the Chief of Staff, the Service Chief, and the Supervisory Audiologist have processes in place to ensure patients affected by the audiologist’s poor care are identified and receive clinically-indicated follow-up.
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2 The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s adverse event disclosure requirements, and takes action as indicated.
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3 The Eastern Oklahoma VA Health Care System Director requires the Chief of Staff, the Service Chief, and the Supervisory Audiologist to complete clinical disclosures, as appropriate, for patients identified as being affected by the audiologist’s poor care.
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4 The Eastern Oklahoma VA Health Care System Director initiates the process to determine whether a large scale disclosure is required, in accordance with the Veterans Health Administration policy.
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5 The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with the Veterans Health Administration’s patient safety reporting requirements, and takes action as indicated.
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6 The Eastern Oklahoma VA Health Care System Director directs the Chief of Staff, the Service Chief, and the Supervisory Audiologist to notify the Patient Safety Manager of adverse events identified through the review of patients impacted by the audiologist’s poor care.
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7 The Eastern Oklahoma VA Health Care System Director ensures the Supervisory Audiologist verifies and documents annual competency assessments for audiologists in compliance with facility policy.
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8 The Eastern Oklahoma VA Health Care System Director ensures that the Supervisory Audiologist conducts performance appraisals of audiologists in compliance with the Veterans Health Administration policy.
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9 The Eastern Oklahoma VA Health Care System Director evaluates processes, including annual competencies, used to ensure audiology leaders’ compliance with Veterans Health Administration’s state licensing board reporting policy, and takes action as indicated.
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10 The Eastern Oklahoma VA Health Care System Director initiates a review of the audiologist’s conduct to determine whether a report to the state licensing board is indicated, in accordance with the Veterans Health Administration policy.
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| 20-00433-168 | VBA’s Fiduciary Program Needs to Improve the Timeliness of Determinations and Reimbursements of Misused Funds | Review | ||
1 The OIG recommended the under secretary for benefits implement a mechanism for ensuring negligence determinations subsequent to December 31, 2017, are completed promptly and monitor compliance.
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2 The OIG recommended the under secretary for benefits implement a mechanism for ensuring reimbursements subsequent to December 31, 2017, are completed promptly and monitor compliance.
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| 20-02993-181 | Deficiencies in the Mental Health Care of a Patient who Died by Suicide and Failure to Complete an Institutional Disclosure, VA Southern Nevada Healthcare System in Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director ensures completion of suicide risk screening and evaluation in accordance with Veterans Health Administration requirements.
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2 The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff collaboratively develop and update safety plans with patients to reflect the patient’s current risk and protective factors.
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3 The VA Southern Nevada Healthcare System Director ensures adherence to Veterans Health Administration requirements and VA Southern Nevada Healthcare System Standard Operating Procedure 116-14, Suicide Prevention Daily Operations, October 2019, in the consideration of high risk for suicide patient record flags.
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4 The VA Southern Nevada Healthcare System Director evaluates substance use disorder diagnostic and treatment referral processes for patients on the Inpatient Mental Health Unit and takes action as warranted.
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5 The VA Southern Nevada Healthcare System Director reviews current practices to ensure Inpatient Mental Health Unit staff reconcile and incorporate critical clinical information into treatment and discharge planning.
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6 The VA Southern Nevada Healthcare System Director expedites the establishment of mental health treatment coordinator policy in accordance with Veterans Health Administration requirements.
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7 The VA Southern Nevada Healthcare System Director makes certain that Inpatient Mental Health Unit staff coordinate discharge plans with outpatient treatment providers, in accordance with Veterans Health Administration requirements.
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8 The VA Southern Nevada Healthcare System Director ensures patient complaints and requests are addressed in accordance with Veterans Health Administration requirements.
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9 The VA Southern Nevada Healthcare System Director promotes leaders’ accurate identification of sentinel events consistent with The Joint Commission definition and Veterans Health Administration requirements.
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10 The VA Southern Nevada Healthcare System Director conducts a full review of the patient’s
care, determines whether an institutional disclosure is warranted, and takes action as indicated.
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| 20-01807-173 | Adaptive Sports Grants Management Needs Improvement | Review | ||
1 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop standard operating procedures for all processes related to managing the adaptive sports grants program.
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2 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director develop and train current staff and identify and hire staff specialized in grants management.
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3 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish and execute a plan to evaluate risks posed by grant applicants before awarding grants, in accordance with VA financial policy.
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4 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish procedures to ensure the timely reimbursement of grant recipient expenses.
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5 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director establish grant closeout procedures that include communicating timelines with the grant recipients, documentation requirements for proper grant closeout, availability of grant funds, and a process to approve modification and extension requests.
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6 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director act to ensure all adaptive sports grants are closed out on time.
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7 The OIG recommended the under secretary for health ensure the Office of National Veterans Sports Programs and Special Events director determine, in coordination with VA’s Office of Finance and Office of General Counsel, whether a Purpose Statute violation occurred, whether account adjustments need to be made, whether Antideficiency Act violations occurred, and report any Purpose Statute and Antideficiency Act violations.
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| 20-01257-180 | Comprehensive Healthcare Inspection of the VA Portland Health Care System in Oregon | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety and Value Council’s recommended improvement actions are fully implemented and monitored.
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2 The System Director evaluates and determines any additional reasons for noncompliance and ensures the Utilization Management Committee’s recommended improvement actions are fully implemented.
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3 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that root cause analyses include all required review elements.
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4 The System Director evaluates and determines any additional reasons for noncompliance and ensures all root cause analysis actions are fully implemented.
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5 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.
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6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment that includes a history of aberrant drug-related behaviors prior to initiating long-term opioid therapy.
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7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct urine drug testing as recommended for patients on long-term opioid therapy.
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8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers obtain and document informed consent for patients prior to initiating long-term opioid therapy.
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9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct follow-up assessments that include adherence to the pain management plan of care and effectiveness of the interventions.
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10 The Chief of Staff evaluates and determines the reasons for noncompliance and ensures that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
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11 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training.
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12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete life-sustaining treatment decisions progress notes prior to hospice referrals.
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13 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that required members attend Women Veterans Health Committee meetings.
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14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders.
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15 The Deputy Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures standard operating procedures are kept up-to-date and reviewed at least every three years.
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16 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Endoscopy Clinic clean storage room maintains the required relative humidity range.
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17 The Deputy Director for Patient Care Services determines the reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
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| 20-01256-179 | Comprehensive Healthcare Inspection of the Boise VA Medical Center in Idaho | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain a licensed healthcare professional’s first- or second-line supervisor completes provider exit review forms within seven business days of professionals’ departure from the medical center.
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2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
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3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator conducts at least five suicide prevention outreach activities per month.
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4 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that all staff complete annual suicide prevention refresher training.
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5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures practitioners complete life-sustaining treatment decision progress notes.
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6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that processes and procedures are in place for 24 hours a day, 7 days per week Emergency Department and medical center call coverage for gynecologic care.
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7 The Medical Center 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 or arrangements for leave coverage when there is only one designated provider.
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8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
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9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
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10 The Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff complete competency assessments that align with medical center standard operating procedures prior to reprocessing reusable medical equipment.
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| 20-00716-177 | Deficiencies in the Completion of Community Care Consults and Leaders’ Oversight at the New Mexico VA Health Care System in Albuquerque | Hotline Healthcare Inspection | ||
1 The New Mexico VA Health Care System Director verifies monitoring is in place to ensure that clinical documentation is obtained from non-VA providers, scanned into the electronic health record, and attached to the applicable consult prior to completion of the consult.
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2 The New Mexico VA Health Care System Director evaluates program effectiveness and monitors the Chief of Community Care’s implementation of the competency and training program for Community Care Service nurses.
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3 The New Mexico VA Health Care System Director confirms the Consult and Access Management Steering Committee updates its charter and oversees all aspects of the consult process as required by the Veterans Health Administration consult management policy.
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4 The New Mexico VA Health Care System Director determines that staff responsible for monitoring and oversight, as identified by the Chief of Staff and the Consult and Access Management Steering Committee, develop and implement a process to evaluate Community Care consult processes and procedures for consistency with Veterans Health Administration policies.
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5 The New Mexico VA Health Care System Director reviews the organizational structure of the facility’s Community Care Department, including available positions, evaluates the expertise of leaders and supervisory staff to ensure effective management and oversight, and takes action as necessary.
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| 20-03229-155 | VBA Overpaid Veterans Due to Delays in Reducing Compensation Benefits | Review | ||
1 Establish, document, and implement a workload management strategy to distribute and process proposals to reduce benefits that minimizes delays and excessive payments.
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2 Develop, document, and implement a formal procedure to routinely monitor the workload management strategy to ensure it minimizes delays and excessive payments.
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| 20-01930-183 | Training Deficiencies with VA’s New Electronic Health Record System at the Mann-Grandstaff VA Medical Center in Spokane, Washington | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health explores the establishment of a group of Veterans Health Administration staff comprised of core user roles with expertise in Veterans Health Administration operations and Cerner electronic health record use with data architect level knowledge to lead the effort of generating optimized Veterans Health Administration clinical and administrative workflows.
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2 The Deputy Secretary establishes an electronic health record training domain that ensures close proximation to the production environment and is readily available to all end users during and following training.
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3 The Deputy Secretary ensures end users receive training time sufficient to impart the skills necessary to use the new electronic health record prior to implementation.
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4 The Deputy Secretary ensures the user role assignment process addresses identified facility leaders and staff concerns.
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5 The Deputy Secretary ensures Cerner trainers and adoption coaches have the capability to deliver end user training on Cerner and Veterans Health Administration electronic health record software workflows.
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6 The Deputy Secretary evaluates the process of super user selection and takes action as indicated.
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7 The Deputy Secretary reviews the Office of Electronic Health Records Modernization’s performance-based service assessments for Cerner’s execution of training to determine whether multiple, recurrent concerns are being accurately captured and addressed.
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8 The Deputy Secretary oversees the revision of an Office of Electronic Health Records Modernization training evaluation plan and ensures implementation of stated objectives.
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9 The Deputy Secretary reviews the Electronic Health Record Modernization governance structure and takes action as indicated to ensure the Under Secretary for Health’s role in directing and prioritizing Electronic Health Record Modernization efforts is commensurate with the Veteran Health Administration’s role in providing safe patient care.
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10 The Under Secretary for Health establishes guidelines and training to capture new electronic health record-related patient complaints, including patient advocacy.
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11 The Under Secretary for Health ensures an assessment of employee morale following implementation of a new electronic health record and takes action as indicated.
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14957