Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-01266-117 | Comprehensive Healthcare Inspection of the Ann Arbor VA Medical Center in Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures action items are fully implemented when problems or opportunities for improvement are identified.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners with similar training and privileges complete ongoing professional practice evaluations.
Closure Date:
3 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 independent practitioners’ departure from the medical center.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that suicide prevention coordinators complete suicide prevention safety plans within the required time frame and include contact information for professional agencies.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that employees complete annual suicide prevention refresher training
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain the Women Veterans Health Committee meets regularly, appoints required members who consistently attend meetings, and reports to executive leaders.
Closure Date:
7 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures the Chief of Sterile Processing Services enforces the endoscopy clinic reprocessing area’s daily cleaning schedule.
Closure Date:
8 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity ranges are monitored and maintained in the Sterile Processing Services main supply room and endoscopy clinic reprocessing area.
Closure Date:
9 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all staff who reprocess reusable medical equipment receive monthly continuing education.
Closure Date:
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| 20-00545-115 | Insufficient Veterans Crisis Line Management of Two Callers with Homicidal Ideation, and an Inadequate Primary Care Assessment at the Montana VA Health Care System in Fort Harrison | Hotline Healthcare Inspection | ||
1 The Veterans Crisis Line Director conducts a full review of the Veterans Crisis Line staff’s management of caller 1’s contacts, including the responder’s conduct, consults with Human Resources and General Counsel Offices, and takes action as warranted.
Closure Date:
2 The Veterans Crisis Line Director ensures leaders’ awareness and understanding of administrative investigation board policy and procedures as applicable to the Veterans Crisis Line.
Closure Date:
3 The Montana VA Health Care System Director ensures that primary care providers include and document assessment and care plans for patients with mental health conditions.
Closure Date:
4 The Montana VA Health Care System Director makes certain that primary care providers comply with Veterans Health Administration policy regarding the electronic health record documentation of patients’ non-VA health records.
Closure Date:
5 The Executive Director, Office of Mental Health and Suicide Prevention, consults with relevant Veterans Health Administration program offices, including the National Center for Patient Safety, to establish applicable quality management processes and expectations including staff reporting of adverse events and close calls.
Closure Date:
6 The Veterans Crisis Line Director evaluates Veterans Crisis Line leaders’ expectations regarding the percentage of silent monitored calls completed and establishes benchmarks for individual staff requirements.
Closure Date:
7 The Veterans Crisis Line Director makes certain that root cause analyses are conducted as required by Veterans Health Administration policy.
Closure Date:
8 The Executive Director, Office of Mental Health and Suicide Prevention, determines if Veterans Health Administration disclosure policies apply to the Veterans Crisis Line and establishes procedures as appropriate.
Closure Date:
9 The Veterans Crisis Line Director ensures processes are developed to promote responders’ communication regarding emergency dispatch for disconnected callers.
Closure Date:
10 The Veterans Crisis Line Director conducts a full review of Veterans Crisis Line staff members’ contacts and rescue management with caller 2, consults with the Human Resources and General Counsel Offices, and takes action as warranted.
Closure Date:
11 The Veterans Crisis Line Director strengthens supervisory oversight of social service assistants and clearly communicates expectations to all supervisory levels.
Closure Date:
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| 20-01386-107 | Quality of Colonoscopies in Multispecialty Community-Based Outpatient Clinics | National Healthcare Review | ||
1 The Under Secretary for Health clarifies requirements for colonoscopy quality indicators for professional practice evaluation and ensures a process is in place to monitor compliance.
Closure Date:
2 The Under Secretary for Health strengthens requirements for colonoscopy quality assurance monitoring that includes analysis of quality indicators to identify trends and monitors for compliance.
Closure Date:
3 The Under Secretary for Health, in conjunction with the National Gastroenterology Program Director, evaluates implementation of standardized endoscopy software across Veterans Health Administration facilities where colonoscopies are performed and takes action as indicated.
Closure Date:
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| 20-02667-93 | Deficiencies in Care and Administrative Processes for a Patient Who Died by Suicide, Phoenix VA Health Care System, Arizona | Hotline Healthcare Inspection | ||
1 The Phoenix VA Health Care System Director conducts a full review of the patient’s care to determine if administrative action is warranted, consulting with Human Resources and General Counsel offices as appropriate.
Closure Date:
2 The Phoenix VA Health Care System Director ensures that staff complete suicide risk assessments consistent with Veterans Health Administration and Phoenix VA Health Care System policies.
Closure Date:
3 The Phoenix VA Health Care System Director ensures timely and accurate completion of electronic health record documentation.
Closure Date:
4 The Phoenix VA Health Care System Director evaluates the community care psychology consult authorization timeliness and takes action as warranted.
Closure Date:
5 The Phoenix VA Health Care System Director conducts a review of Primary Care Clinic missed appointment procedures and ensures patient follow-up and staff training, as appropriate.
Closure Date:
6 The Phoenix VA Health Care System Director evaluates scheduling accuracy of mental health community care psychology consults and takes action as appropriate.
Closure Date:
7 The Phoenix VA Health Care System Director ensures timely completion of behavioral health autopsies, consistent with Veterans Health Administration policy, and monitors for ongoing compliance.
Closure Date:
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| 19-00652-79 | Alleged Irregularities Regarding Physician Incentive Compensation Were Not Substantiated | Administrative Investigation | ||
1 The Medical Center Director audits the Dental Service Chief’s relative value unit productivity metric for fiscal years 2018 and 2019 and determines whether any erroneous payments for performance were made and issues bills of collection if deemed appropriate.
Closure Date:
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| 20-02717-85 | Review of Veterans Health Administration’s Virtual Primary Care Response to the COVID-19 Pandemic | National Healthcare Review | ||
1 The Under Secretary for Health evaluates veteran access to VA Video Connect, including availability of equipment and reliable internet connectivity necessary to use VA Video Connect, and takes appropriate action.
Closure Date:
2 The Under Secretary for Health reviews the provision of veteran VA Video Connect training and support, and takes appropriate action.
Closure Date:
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| 20-00427-92 | View Alert Process Failures and the Impact on Patient Care at the Central Alabama Veterans Health Care System in Montgomery | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health maintains consistent acting or interim leaders and expedites hiring of permanent leaders at the Central Alabama Veterans Health Care System.
Closure Date:
2 The VA Southeast Network Director ensures continued collaboration with the Central Alabama Veterans Health Care System to facilitate compliance with guidelines related to view alert management and monitors for ongoing efficiency and sustainability.
Closure Date:
3 The Central Alabama Veterans Health Care System Director will continue to evaluate and assess the Central Alabama Veterans Health Care System’s view alert management process, effectiveness of its action plan, and modify as indicated.
Closure Date:
4 The Central Alabama Veterans Health Care System Director ensures that initial and ongoing provider training and support for the clinical management of view alerts is provided, and monitors compliance.
Closure Date:
5 The Central Alabama Veterans Health Care System Director issues guidance and ensures providers are trained on a clearly defined process for the designation of surrogates and the associated responsibilities, and monitors compliance.
Closure Date:
6 The Central Alabama Veterans Health Care System Director evaluates the two cases discussed in this report to determine if an institutional disclosure or formal quality management review is needed and takes action accordingly.
Closure Date:
7 The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on the unmanaged abnormal laboratory test and imaging results to include those that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
Closure Date:
8 The Central Alabama Veterans Health Care System Director conducts a retrospective review focusing on unscheduled community care consults that were discontinued after 90 days that have the most potential for adverse clinical outcomes to ensure patients received follow-up care as required by Veterans Health Administration policy.
Closure Date:
9 The Central Alabama Veterans Health Care System Director ensures the development and implementation of a policy to address the communication of all test results to ordering providers, or designee, and to patients as required by Veterans Health Administration policy, and monitors compliance.
Closure Date:
10 The Central Alabama Veterans Health Care System Director ensures that audits of abnormal laboratory and imaging test results, and unscheduled community care consults that were discontinued after 90 days, are completed to verify providers have managed the associated view alerts, and monitors compliance.
Closure Date:
11 The Central Alabama Veterans Health Care System Director ensures that pending actions are completed for the 33 patient cases with clinical issues referred to the system by the Office of the Inspector General.
Closure Date:
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| 20-01387-89 | Colonoscope Reprocessing at Multispecialty Community-Based Outpatient Clinics | National Healthcare Review | ||
1 The Under Secretary for Health requires facility directors ensure that staff who reprocess colonoscopes at community-based outpatient clinics complete initial training within the required 90 days prior to independently reprocessing equipment and maintain documentation.
Closure Date:
2 The Under Secretary for Health requires facility directors confirm that sterile processing services staff who reprocess colonoscopes at community-based outpatient clinics receive ongoing continuing education through monthly in-services and maintain documentation.
Closure Date:
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| 20-00102-73 | Handling Administrative Errors at the Chicago VA Regional Benefits Office in Illinois | Review | ||
1 The director of the Chicago VA regional benefits office ensure the errors identified by the review team are corrected.
Closure Date:
2 The director of the Chicago VA regional benefits office monitor the effectiveness of the actions taken to improve the accuracy of administrative error corrections, and determine what additional measures, if any, are needed to make certain that claims processors understand how to apply national and local procedures for correcting administrative errors.
Closure Date:
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| 19-06147-50 | Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Distribution Fee Invoicing | Audit | ||
1 Direct the Medical Supplies Program Office to implement procedures requiring chief logistics officers at Veterans Integrated Service Networks to monitor facility processes for verification and certification of distribution fee invoices to ensure invoice accuracy prior to payment by the Financial Services Center.
Closure Date:
2 Require Veterans Integrated Service Network directors to ensure their chief logistics officers develop distribution fee monitoring and review procedures for facility logistics audits and compliance reviews to ensure invoices are adequately reviewed, verified, and certified.
Closure Date:
3 Require Veterans Integrated Service Network directors to ensure facility chief logistics officers and contracting officer’s representatives review and update the election forms according to contract requirements and provide copies to the Medical/Surgical Prime Vendors for acknowledgment.
Closure Date:
4 Require Veterans Integrated Service Network directors to ensure facility contracting officer’s representatives verify that distribution fee rates match with those on the election forms and pricing schedule by comparing transaction data from the vendors to VHA-maintained transaction data, and reconcile payments as appropriate.
Closure Date:
5 Require the Strategic Acquisition Center to develop and add modifications to the Medical/ Surgical Prime Vendor-Next Generation contract requiring prime vendors to provide reports to VA medical facilities with detailed medical and surgical transaction data, fee amounts, and fee percentage rates applied to each transaction on distribution fee invoices.
Closure Date:
6 Require the Strategic Acquisition Center contracting officer to work with the Medical Supplies Program Office to ensure that Medical/Surgical Prime Vendor contracting officer’s representatives are assigned to each VA medical facility.
Closure Date:
7 Require the Strategic Acquisition Center to appropriately modify the Medical/Surgical Prime Vendor contract to define annual facility purchase as well as adding a provision for paying the annual facility purchase amount based on the estimated total spend until year-end reconciliation.
Closure Date:
8 Require the Strategic Acquisition Center to also appropriately modify the Medical/ Surgical Prime Vendor contract to require the prime vendors—rather than the facility—to reconcile to annual facility purchases at the end of the year.
Closure Date:
9 Require the Medical Supplies Program Office to establish policy that clearly defines the source VA medical facilities should use to estimate their annual facility purchase amounts and determine the year-end amounts.
Closure Date:
10 Require VA medical facilities to review their on-site representative fees paid during fiscal year 2018 and future years to ensure they were paid based on the actual annual facility purchase amounts, consistent with the Medical/Surgical Prime Vendor-Next Generation contract, and reconcile payment discrepancies as appropriate.
Closure Date:
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15039