Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-00178-24 | Program of Comprehensive Assistance for Family Caregivers: IT System Development Challenges Affect Expansion | Audit | ||
1 The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, establish policies and procedures for joint governance by OIT and program offices on all information.
Closure Date:
2 The OIG recommended the acting assistant secretary for information and technology require the Office of Information and Technology to develop controls for making certain the program management review process is consistently enforced for future information technology projects to deliver and sustain the intended outcomes and to ensure underperforming projects are identified for evaluation by the Program and Acquisition Review Council.
Closure Date:
3 The OIG recommended the acting assistant secretary for information and technology, in conjunction with the acting under secretary for health, reevaluate the risk determination for the Caregiver Record Management Application and determine if the system should be set to a security categorization level of high based on the personal health information and other sensitive data maintained therein.
Closure Date:
4 The OIG recommended the acting assistant secretary for information and technology establish VA wide policies and responsibilities for managing VA information technology projects under the Development Operations process.
Closure Date:
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| 20-03535-146 | Delay in a Patient’s Emergency Department Care at the Malcom Randall VA Medical Center in Gainesville, Florida | Hotline Healthcare Inspection | ||
1 The North Florida/South Georgia Veterans Health System Director evaluates processes and implements a requirement as necessary that Emergency Severity Index level 2 patients do not remain in the Emergency Department waiting room.
Closure Date:
2 The North Florida/South Georgia Veterans Health System Director evaluates if additional quality reviews are needed due to failures identified in this report regarding the patient’s pre-code Emergency Department care, and takes action as indicated.
Closure Date:
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| 18-02496-157 | Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health ensures that the Veterans Health Administration competency process for locum tenens, newly hired specialty care providers, and newly hired service chiefs is evaluated to confirm that the results of the assessment accurately reflects the clinical competency of providers who are privileged, and takes action, as indicated.
Closure Date:
2 The Under Secretary for Health reviews current Veterans Health Administration credentialing and privileging policies to assess guidance related to service chiefs’ ongoing professional practice evaluation and takes action, as indicated.
Closure Date:
3 The Under Secretary for Health reviews Veterans Health Administration policies to ensure that if facility leaders elect to incorporate pathology 10 percent peer reviews into the performance evaluations of a Pathology and Laboratory Medicine Service Chief, those reviews are performed by a peer without a conflict of interest and takes action, as indicated.
Closure Date:
4 The Under Secretary for Health evaluates the use and methodology of the Pathology and Laboratory Medicine Service 10 percent peer review for effectiveness as a quality management tool, and takes action, as indicated.
Closure Date:
5 The Under Secretary for Health evaluates Veterans Health Administration guidance related to amended pathology reports’ terminology, use, and entry of such reports into patients’ electronic health records, and revises guidance, as appropriate.
Closure Date:
6 The Under Secretary for Health confirms that provisions are included in the Veterans Health Administration record modernization program that ensure amended pathology report alerts are directed to designated facility staff and leaders.
Closure Date:
7 The Under Secretary for Health evaluates Veterans Health Administration quality management processes related to external, non-VHA pathology consultant assessments and ensures that facility leaders, the specialty care provider, and requesting providers are notified of the results of such reviews and a tracking process is in place.
Closure Date:
8 The Under Secretary for Health confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, & Preparedness to determine whether administrative action is warranted for Veterans Health Administration leaders who did not adequately perform their duties with respect to the issues within this report, and takes action, as appropriate.
Closure Date:
9 The Under Secretary for Health explores the development of a mandatory alcohol testing policy for individuals including healthcare workers who perform functions that would put patients at risk should the employee work while impaired.
Closure Date:
10 The Under Secretary for Health evaluates Veterans Health Administration’s guidance related to impaired healthcare workers and ensures that it addresses the circumstances under which alcohol and or drug testing may be performed; the extent of a retrospective review of care if one is indicated; and the availability of advisors who are knowledgeable on the management of an impaired provider, and takes action, as indicated.
Closure Date:
11 The Veterans Health Care System of the Ozarks Director verifies that peer references obtained during the reappraisal and reprivileging processes are in alignment with VHA Handbook 1100.19, Credentialing and Privileging.
Closure Date:
12 The Veterans Health Care System of the Ozarks Director evaluates the psychological safety climate to ensure facility staff, patients, and the general public are empowered to report concerns and unsafe patient care without fear of reprisal and takes action, as needed.
Closure Date:
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| 20-01267-148 | Comprehensive Healthcare Inspection of the Battle Creek VA Medical Center in Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director determines the reasons for noncompliance and ensures specific action items are recommended, implemented, and monitored when problems and opportunities for improvement are identified.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that an interdisciplinary committee reviews utilization management data as required.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete provider exit review forms within seven business days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and effectiveness of pain management interventions.
Closure Date:
5 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 documented patient preference, within the required time frame.
Closure Date:
6 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women’s Health Advisory Committee meetings.
Closure Date:
7 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:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator
Closure Date:
9 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that standard operating procedures align with the manufacturers’ guidelines and instructions for use.
Closure Date:
10 The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
11 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services employees complete valid competency assessments prior to reprocessing reusable medical equipment.
Closure Date:
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| 20-01268-143 | Comprehensive Healthcare Inspection of the Chillicothe VA Medical Center in Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analysis is reviewed quarterly by the Medical Staff Executive Council.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Patient Safety Manager monitors implemented root cause analysis action items for sustained improvement.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a licensed healthcare professional’s first- or second-line supervisor correctly completes and signs an exit review form within seven business days of the professional’s departure from the medical center.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Opioid Safety Review Board monitors the quality of pain assessment and effectiveness of pain management interventions.
Closure Date:
7 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete suicide prevention training as required.
Closure Date:
8 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required Women Veterans Health Committee members are assigned and consistently attend meetings, and that the committee reports to the Medical Staff Executive Council.
Closure Date:
9 The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures standard operating procedures are current, align with manufacturers’ guidelines/instructions for use, and are reviewed at least every three years or when there is a change.
Closure Date:
10 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that commercial airflow directional devices are used in areas where reusable medical equipment is reprocessed and stored.
Closure Date:
11 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that all Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
12 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employee competency assessments align with medical center standard operating procedures.
Closure Date:
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| 20-00817-123 | Compensation and Pension Proceeds Were Generally Handled Accurately but Some Were Delayed | Audit | ||
1 Implement a timeliness requirement or performance measure for handling proceeds.
Closure Date:
2 Develop oversight and monitoring procedures to ensure timely handling of proceeds.
Closure Date:
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| 20-03178-116 | Deficiencies in Reporting Reliable Physical Infrastructure Cost Estimates for the Electronic Health Record Modernization Program | Audit | ||
1 The executive director for the Office of Electronic Health Record Modernization should ensure an independent cost estimate is performed for program life cycle cost estimates including related physical infrastructure costs funded by the Veterans Health Administration.
Closure Date:
2 The VA Assistant Secretary for Management and Chief Financial Officer should ensure the Office of Programming, Analysis and Evaluation, or another office performing its duties, conducts independent cost
Closure Date:
3 The director of Special Engineering Projects for the Veterans Health Administration’s Office of Healthcare Environment and Facilities Programs should develop a reliable cost estimate for Electronic Health Record Modernization program-related physical infrastructure in accordance with VA cost-estimating standards and incorporate costs for upgrade needs identified in facility self-assessments and scoping sessions.
Closure Date:
4 The director of Special Engineering Projects should also continuously update physical infrastructure cost estimates based on emerging requirements and identified project needs.
Closure Date:
5 Ensure costs for physical infrastructure upgrades funded by the Veterans Health Administration or other sources needed to support the Electronic Health Record Modernization program are disclosed in program life cycle cost estimates presented to Congress.
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| 20-03380-136 | Drug Interactions Related to a Patient Death, Marion VA Medical Center in Illinois | Hotline Healthcare Inspection | ||
1 The Marion VA Medical Center Director ensures that behavioral health staff provide, and document patient education including discussion of side effects and possible adverse drug-drug interactions during telephone encounters when medications are added or adjusted and monitors compliance.
Closure Date:
2 The Marion VA Medical Center Director confirms that behavioral health providers are communicating test results to patients and providing necessary clinical interventions as required by policy.
Closure Date:
3 The Marion VA Medical Center Director monitors implementation of Phase Four of the Psychotropic Drug Safety Initiative.
Closure Date:
4 The Marion VA Medical Center Director ensures that primary care providers enter return-to-clinic orders and monitors compliance.
Closure Date:
5 The Marion VA Medical Center Director verifies primary care and behavioral health staff document contacts, attempted contacts, and letters sent when patients missed their appointments and monitors compliance.
Closure Date:
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| 20-01276-131 | Comprehensive Healthcare Inspection of the Cincinnati VA Medical Center in Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, and Value Committee fully implements and monitors improvement actions.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and makes certain that all applicable deaths are peer reviewed.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that root cause analyses include all required review elements.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria for focused professional practice evaluations in practitioner profiles.
Closure Date:
5 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs document the results of focused professional practice evaluations in practitioner profiles.
Closure Date:
6 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that service chiefs collect service-specific ongoing professional practice evaluation data.
Closure Date:
7 The Chief of Staff determines the reasons for noncompliance and ensures service chiefs recommend continuation of privileges based on ongoing professional practice evaluation data.
Closure Date:
8 The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Clinical Executive Board meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend initiation and continuation of privileges.
Closure Date:
9 The Medical Center 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 medical center.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinicians complete suicide prevention safety plans in the expected time frame for patients with High Risk for Suicide Patient Record Flags.
Closure Date:
11 The Chief of Staff 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 plans for leave coverage if there is only one designated provider.
Closure Date:
12 The Chief of Staff determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Advisory Committee meetings.
Closure Date:
13 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturer’s instructions for use.
Closure Date:
14 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that CensiTrac® is fully operational.
Closure Date:
15 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services maintains written records of weekly eyewash station function testing.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that staff who reprocess reusable medical equipment receive monthly continuing education.
Closure Date:
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| 20-00049-122 | The Office of Field Operations Did Not Adequately Oversee Quality Assurance Program Findings | Review | ||
1 Develop and implement a written plan to strengthen oversight of the quality assurance program for disability compensation benefits and monitor the plan to ensure identified deficiencies are adequately addressed.
Closure Date:
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14957