Recommendations
2128
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-01917-242 | Mismanagement of a Patient at the Tomah VA Medical Center in Wisconsin | Hotline Healthcare Inspection | ||
1 The Tomah VA Medical Center Director ensures that providers receive education regarding the management of alcohol withdrawal and delirium tremens, and monitors compliance.
Closure Date:
2 The Tomah VA Medical Center Director makes certain providers consider patients’ underlying cardiac risk prior to the order of haloperidol.
Closure Date:
3 The Tomah VA Medical Center Director conducts a comprehensive review of the patient’s cardiopulmonary resuscitation event to determine potential causes of failed oxygen delivery including systemic root causes and performance deficiencies, and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel action is warranted and takes action.
Closure Date:
4 The Tomah VA Medical Center Director implements actions recommended by the Out of Operating Room Airway Management workgroup, and monitors compliance.
Closure Date:
5 The Tomah VA Medical Center Director evaluates staff adherence to the Tomah VA Medical Center Policy MS-25, Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Protocol and the Standard Operating Procedure for Nursing Procedure, Symptom Triggered CIWA-Ar Protocol, and takes action to ensure compliance.
Closure Date:
6 The Tomah VA Medical Center Director ensures inpatient medical unit providers and nursing staff compliance with patient restraint management, as required by to the Tomah VA Medical Center Policy, PCS-03, Restraint and Seclusion Use.
Closure Date:
7 The Tomah VA Medical Center Director monitors provider compliance with Tomah VA Medical Center Policy MS-06, Admission Criteria for Acute Medicine Unit.
Closure Date:
8 The Tomah VA Medical Center Director consults with the Office of General Counsel to ensure the Tomah VA Medical Center Policy PCS-SW-17 Emergency Detention is consistent with Wisconsin law.
Closure Date:
9 The Tomah VA Medical Center Director strengthens processes for staff to consider next of kin or family notification in the emergency detention of patients who may not comprehend their legal rights.
Closure Date:
10 The Tomah VA Medical Center Director ensures compliance with institutional disclosure procedures, as required by the Veterans Health Administration.
Closure Date:
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| 21-01502-240 | Comprehensive Healthcare Inspection Summary Report: Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, Fiscal Year 2020 | National Healthcare Review | ||
1 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement action items recommended by the committees responsible for quality, safety, and value oversight functions.
Closure Date:
2 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, makes certain that facilities peer review all applicable suicides.
Closure Date:
3 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that root cause analyses include a review of the underlying systems to determine where system redesigns might reduce risk.
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4 The Under Secretary for Health, in conjunction with Veterans Integrated Service Network directors and facility senior leaders, ensures that facilities fully implement approved root cause analysis action items and outcome measures show sustained improvement.
Closure Date:
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| 21-00246-228 | Comprehensive Healthcare Inspection of the VA Eastern Colorado Health Care System in Aurora | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator participates on the Quality Safety Values Executive Council.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Staff regularly attends Surgical Work Group meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures staff complete suicide safety plan training prior to developing suicide safety plans.
Closure Date:
4 The System Director evaluates and determines reasons for noncompliance and makes certain that a written policy is in place to ensure the safe, appropriate, orderly, and timely transfer of patients.
Closure Date:
5 The System Director evaluates and determines additional reasons for noncompliance and ensures that all patient transfers are monitored and evaluated as part of Veterans Health Administration’s Quality Management Program.
Closure Date:
6 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine the reasons for noncompliance and ensure that staff send pertinent medical records, including an active patient medication list, to the receiving facility during inter-facility transfers.
Closure Date:
7 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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| 21-00371-222 | Deficiencies in the Assessment and Care of a Patient Seeking Geriatric Services at the Fayetteville VA Medical Center in North Carolina | Hotline Healthcare Inspection | ||
1 The Fayetteville VA Medical Center Director ensures that community health nurses evaluate patients referred for homemaker and/or home health aide services in accordance with Veterans Health Administration policy when determining patient eligibility.
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2 The Fayetteville VA Medical Center Director verifies that interdisciplinary assessments of homemaker and/or home health aide referrals are completed to determine patient eligibility for services.
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3 The Fayetteville VA Medical Center Director ensures that community health staff are trained on the eligibility criteria for homemaker and/or home health aide services.
Closure Date:
4 The Fayetteville VA Medical Center Director evaluates staff compliance with Veterans Health Administration and state of North Carolina commitment requirements, confirms staff understanding of required processes, and consults with the Office of General Counsel regarding state law, as warranted.
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5 The Fayetteville VA Medical Center Director ensures that providers consistently assess and document when patients lack decision-making capacity.
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6 The Fayetteville VA Medical Center Director ensures thatproviders consistently determine whether a patient has an identified healthcare agent when patients lack decision-making capacity.
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7 The Fayetteville VA Medical Center Director makes certain that patient aligned care team providers and outpatient psychiatrists are educated about initiating specialty care consults for patients.
Closure Date:
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| 20-03359-220 | Deficiencies in Coordination of Care for Patients with Treatment-Resistant Depression at the VA San Diego Healthcare System in California | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health requires that all community care providers authorized to provide ketamine or esketamine for treatment-resistant depression receive and review VA’s National Protocol Guidance on ketamine infusion and intranasal esketamine.
Closure Date:
2 The Under Secretary for Health evaluates the need for conducting research on the use of ketamine and esketamine for treatment-resistant depression including the comparative efficacy of ketamine and esketamine, the effect of route of administration, therapeutic dose range, mechanism of action, and efficacy and safety of long-term treatment, and initiates research efforts as indicated.
Closure Date:
3 The VA San Diego Healthcare System Director confirms that the facility’s Community Care Service takes timely actions to ensure that administrative processes for care authorization do not disrupt continuity of clinical care.
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4 The VA San Diego Healthcare System Director makes certain that the facility’s Community Care Service processes incorporate relevant clinical service input in decisions regarding authorization, denial, or discontinuation of care.
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5 The VA San Diego Healthcare System Director ensures that the facility’s Community Care Service processes incorporate a consistent mechanism for communication with Veterans Health Administration and community clinical providers and patients to facilitate well-timed coordination of care.
Closure Date:
6 The VA San Diego Healthcare System Director monitors implementation of the coordinated, clinically informed plans for continuing care when transitioning the remaining patients from ketamine treatment in the community to care at the facility.
Closure Date:
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| 21-00232-205 | Comprehensive Healthcare Inspection of the Montana VA Health Care System in Fort Harrison | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures that the Systems Redesign and Improvement Coordinator reports directly to the Director or one supervisory level below the Director.
Closure Date:
2 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group meets monthly and core members consistently attend meetings.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Surgical Work Group reviews surgical deaths and National Surgery Office surgical quality reports, analyzes efficiency and utilization metrics, and recommends appropriate actions to the System Director.
Closure Date:
4 The System Director evaluates and determines any additional reasons for noncompliance and ensures that specific action items are implemented and monitored when problems or opportunities for improvement are identified.
Closure Date:
5 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:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that staff complete mandatory training prior to developing suicide safety plans.
Closure Date:
7 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
8 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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| 20-01508-214 | Review of Veterans Health Administration Staffing Models | National Healthcare Review | ||
1 The Under Secretary for Health coordinates with VA to review the roles, responsibilities, and number of staff required for the VA and Veterans Health Administration offices involved in the development, validation, and implementation of staffing models, and ensure that staffing model-related efforts are prioritized and supported.
2 The Under Secretary for Health coordinates with VA to evaluate the status of, and provide a timeline for, the development, validation, and implementation of Veterans Health Administration staffing models for all occupations.
Closure Date:
3 The Under Secretary for Health coordinates with VA to evaluate the status of, and provide a timeline for, the implementation of HR Smart-related requirements referenced in VA and Veterans Health Administration policy, with a specific focus on the authorizations, vacancies, budgeted positions, and unbudgeted requirements at the facility, Veterans Integrated Service Network, and national levels.
Closure Date:
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| 20-03635-217 | Deficiencies in COVID-19 Screening and Facility Response for a Patient Who Died at the Michael E. DeBakey VA Medical Center in Houston, Texas | Hotline Healthcare Inspection | ||
1 The Michael E. DeBakey VA Medical Center Director evaluates the visitor standard operating procedures for patients who require mental or behavioral health support during COVID-19 screening, and takes action as needed.
Closure Date:
2 The Michael E. DeBakey VA Medical Center Director ensures that clinical staff screen and manage suspected COVID-19 patients according to Veterans Health Administration and Veterans Integrated Service Network 16 guidelines and Michael E. DeBakey VA Medical Center policies.
Closure Date:
3 The Michael E. DeBakey VA Medical Center Director monitors compliance with the Veterans Health Administration requirement for Mental Health Intensive Case Management staff to identify and accurately document patients’ surrogates.
Closure Date:
4 The Michael E. DeBakey VA Medical Center Director strengthens processes to ensure Mental Health Intensive Case Management staff inform patients, families, and other support persons on the procedures for accessing medical and mental health care while navigating the COVID-19 screening and testing process, including visitor policies.
Closure Date:
5 The Michael E. DeBakey VA Medical Center Director ensures clinical and non-clinical staff comply with Veterans Health Administration and Michael E. DeBakey VA Medical Center policies on missing and at-risk patients.
Closure Date:
6 The Michael E. DeBakey VA Medical Center Director monitors compliance with Veterans Health Administration policies related to timeliness and reporting of adverse events to the patient safety manager.
Closure Date:
7 The Michael E. DeBakey VA Medical Center Director ensures that issue briefs are initiated timely and are comprehensive, accurate, and updated as appropriate.
Closure Date:
8 The Michael E. DeBakey VA Medical Center Director ensures leaders complete root cause analyses within 45 days of leaders’ awareness of applicable adverse events.
Closure Date:
9 The Michael E. DeBakey VA Medical Center Director consults with the VA Office of General Counsel regarding the accuracy and content of the institutional disclosure to the subject patient’s family, and takes action as appropriate.
Closure Date:
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| 21-00247-210 | Comprehensive Healthcare Inspection of the VA Western Colorado Health Care System in Grand Junction | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board reviews aggregated quality, safety, and value data.
Closure Date:
2 The Executive Director evaluates and determines any additional reasons for noncompliance and ensures that the Quality Safety Value Board’s recommended improvement actions are fully implemented and monitored.
Closure Date:
3 The Executive 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:
4 The Chief of Staff and Associate Director for Patient Care Services evaluate and determine any additional reasons for noncompliance and ensure all required representatives attend Disruptive Behavior Committee meetings.
Closure Date:
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| 20-00418-166 | Ineffective Governance of Prescription Drug Return Program Creates Risk of Diversion and Limits Value to VA | Audit | ||
1 The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel secure prescription drugs set aside for return credit either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
Closure Date:
2 The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel account for all prescription drugs set aside for return credit when they leave the medical facility either by following procedures outlined in VHA Directive 1108.07(1) or by adhering to a superseding policy.
Closure Date:
3 The OIG recommends that the under secretary for health ensure that responsible VA medical facility personnel maintain inventory management practices to make sure drugs that are returned for credit are returned in a timely manner, so that medical facilities do not miss opportunities to maximize the value of their drug returns or reduce their risk of overspending to replace drugs prematurely returned for credit.
Closure Date:
4 The OIG recommends that the under secretary for health takes steps to provide all offices and positions with defined national, network, or facility responsibilities for the drug return program or the administration of any future drug return contract(s), to include Pharmacy Benefits Management Services, Veterans Integrated Service Network pharmacist executives, network contracting officers, contracting officer representatives, and medical facility pharmacy chiefs, with the support, such as training, and the authority needed to carry out those responsibilities.
Closure Date:
5 The OIG recommends that the under secretary for health makes sure that Pharmacy Benefits Management Services reviews the drug return contractor(s) data for accuracy, and uses this data to identify unusual reimbursement patterns and potential improvements for revenue recovery through the last invoices issued as part of the October 2018 Pharma Logistics contract, and for any future drug return contract(s); and coordinate with the National Contract Service on corrective action if inaccurate contractor data is identified.
Closure Date:
6 The OIG recommends that the under secretary for health implements mechanisms to make sure that contracting officer representatives, if assigned, or Veterans Health Administration network contracting officers, provide oversight to ensure the contractor is performing in accordance with the terms of any future drug return contract(s).
Closure Date:
7 The OIG recommends that the under secretary for health, to minimize the risk of errors, makes sure that Veterans Health Administration network contracting officers when writing task orders off any future drug return contract(s) use a template with terms that align with any future drug return contract(s) developed by the National Contract Service.
Closure Date:
8 The OIG recommends that the under secretary for health coordinate with the VA Office of Acquisition, Logistics, and Construction’s principal executive director, who should develop a task order template with terms that align with any future drug return contract(s) and require the National Contract Service to disseminate the template to Veterans Health Administration network contracting officers.
Closure Date:
Total Monetary Impact of All Recommendations
Open: $0
Closed: $14,907,365
Total: $14,907,365
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15333