Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-01036-70 | Misconduct by a Gynecological Provider at the Gulf Coast Veterans Health Care System in Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates review of policies related to the role and training requirements of providers, including gynecologists, who conduct sensitive exams, to determine the need for the inclusion of trauma-informed care principles into training, policy, and practice.
Closure Date:
2 The Under Secretary for Health ensures a review of policies related to the role and training requirements of chaperones for sensitive examinations and takes action as appropriate.
3 The South Central VA Health Care Network Director evaluates processes for tracking patient complaints, takes appropriate action to ensure that facility staff enter all complaints into the Patient Advocate Tracking System, and ensures that the data are tracked, trended, and analyzed to identify significant issues and trends.
Closure Date:
4 The Gulf Coast Veterans Health Care System Director ensures staff education of the Veterans Health Administration and Gulf Coast Veterans Health Care System policies related to employee misconduct and monitors compliance.
Closure Date:
5 The Gulf Coast Veterans Health Care System Director reviews and evaluates policies related to administrative investigations, including fact-finding reviews and administrative investigation boards, to ensure such investigations are timely, objective, and documentation is sufficient to address the event under review.
Closure Date:
6 The Gulf Coast Veterans Health Care System Director and facility leaders review the subject gynecologist’s conduct and quality of care provided and meet all Veterans Health Administration requirements for state licensing board and National Practitioner Data Bank reporting.
Closure Date:
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| 20-01271-64 | Comprehensive Healthcare Inspection of the Dayton VA Medical Center in Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs include the minimum specialty-specific criteria for professional practice evaluations of licensed independent practitioners.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and makes certain that service chiefs complete and document focused professional practice evaluations on all newly hired licensed independent practitioners and evaluation results are reviewed and documented by the Clinical Executive Board.
Closure Date:
4 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
5 The Medical Center Director determines reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
6 The Medical Center Director determines the reasons for noncompliance and makes certain that the Multidisciplinary Pain Management Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that qualified providers conduct four follow-up visits within 30 days of a High Risk for Suicide Patient Record Flag placement.
Closure Date:
8 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that clinicians complete patient safety plans within seven days before or after the current High Risk for Suicide Patient Record Flag date.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that life-sustaining treatment plans for patients who lack both decision-making capacity and a surrogate are referred to and reviewed by the assigned multidisciplinary committee.
Closure Date:
10 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center’s Women Veterans Program Manager is free of collateral duties.
Closure Date:
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| 20-02779-59 | Medication Delivery Delays Prior to and During the COVID-19 Pandemic at the Manila Outpatient Clinic in Pasay City, Philippines | Hotline Healthcare Inspection | ||
1 The VA Manila Outpatient Clinic Manager evaluates the current pharmacy ordering processes and takes action to reduce the frequency of pharmacy stock shortages.
Closure Date:
2 The VA Manila Outpatient Clinic Manager reviews the impact of nonworking hours, including holidays, on pharmacy processing delays and takes action as necessary.
Closure Date:
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| 17-01980-201 | False Statements and Concealment of Material Information by VA Information Technology Staff | Administrative Investigation | ||
1 The Assistant Secretary for Information and Technology and Chief Information Officer confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the OIT program manager’s conduct.
Closure Date:
2 The Executive in Charge, Veterans Health Administration, confers with the Office of General Counsel and the Office of Human Resources and Administration/Operations, Security, and Preparedness to determine, given the facts and circumstances, whether any administrative action should be taken with respect to the VHA employee’s conduct.
Closure Date:
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| 20-02339-35 | VA Needs to Comply Fully with the Geospatial Data Act of 2018 | Audit | ||
1 The acting assistant secretary for Enterprise Integration, in conjunction with the assistant secretary for Information and Technology, complies with requirement 3 in section 759(a) of the Geospatial Data Act to establish mandatory VA wide policies and responsibilities to promote the integration of geospatial data.
Closure Date:
2 The assistant secretary for Information and Technology, in conjunction with the director of Enterprise Records Service, establishes a process to ensure geospatial data and activities are included on VA record schedules that have been approved by the National Archives and Records Administration in accordance with requirement 4 of the law.
Closure Date:
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| 18-01321-56 | Thoracic Surgery Quality of Care Issues and Facility Leaders’ Response at the C.W. Bill Young VA Medical Center in Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health designates a thoracic specialty leader who has the authority to review all aspects of the personnel and management actions and can provide unbiased, authoritative, and timely guidance to facilities on the most clinically sound course of action when a thoracic surgeon’s practice or outcomes are under review, in order to ensure that VA provides high quality care.
Closure Date:
2 The Under Secretary for Health outlines general parameters and triggers for when facilities without local thoracic surgery expertise engage the thoracic specialty leader and how the thoracic specialty leader’s decisions and guidance will be documented.
Closure Date:
3 The Under Secretary for Health clarifies Veterans Health Administration policy regarding providers’ responsibilities to document complications in operative reports.
Closure Date:
4 The Under Secretary for Health reevaluates the eligible and mandatory assessment surgery cases reported to the National Surgery Office to determine if thoracic cases should be included in the list of mandatory assessment cases, and modifies the list as appropriate.
Closure Date:
5 The Under Secretary for Health defines expectations for peer review committee members whose cases are being reviewed to leave the room during those deliberations, provides guidance on how that recusal is to be annotated in the Peer Review Committee minutes, and updates Veterans Health Administration policy, as needed.
Closure Date:
6 The C.W. Bill Young VA Medical Center Director enhances processes to identify the existence of omissions or misrepresentations in operative note documentation and takes action based on identified deficiencies, if any.
Closure Date:
7 The C.W. Bill Young VA Medical Center Director takes action to ensure that the surgeon is aware of, and complies with, expectations for professional communications and supporting staff to report adverse events and close calls.
Closure Date:
8 The C.W. Bill Young VA Medical Center Director ensures the C.W. Bill Young VA Medical Center Surgical Work Group provides oversight as required by Veterans Health Administration policy and monitors for compliance.
Closure Date:
9 The C.W. Bill Young VA Medical Center Director confirms processes are in place to ensure providers’ clinical privileges are specific to the facility and service, and are based on each provider’s clinical competence, and monitors for compliance.
Closure Date:
10 The C.W. Bill Young VA Medical Center Director reviews whether the cases reflected in tables 1 and 2 in this report meet criteria for institutional disclosure and takes action as appropriate.
Closure Date:
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| 20-02359-52 | Deficiencies in Privileging a Urologist to Practice and Medication Management Processes at the VA Central Iowa Health Care System in Des Moines | Hotline Healthcare Inspection | ||
1 The VA Central Iowa Health Care System Director ensures sustained compliance of providers who order controlled substances maintaining an individual Drug Enforcement Administration registration.
Closure Date:
2 The VA Central Iowa Health Care System Director ensures verbal medication orders given in the operating room comply with Veterans Health Administration and VA Central Iowa Health Care System policies to permit verbal orders in emergent situations.
Closure Date:
3 The VA Central Iowa Health Care System Director ensures operating room verbal medication orders are entered in the Computerized Patient Record System pharmacy package in accordance with Veterans Health Administration and VA Central Iowa Health Care System policies.
Closure Date:
4 The VA Central Iowa Health Care System Director ensures that verbal medication orders given in the operating room are reviewed by a pharmacist in accordance with VA Central Iowa Health Care System policy.
Closure Date:
5 The VA Central Iowa Health Care System Director ensures that controlled substance inspections include verification of medication orders for controlled substances removed from the operating room automated dispensing cabinet.
Closure Date:
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| 20-01521-48 | Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient’s Death by Suicide, Harry S. Truman Memorial Veterans’ Hospital in Columbia, Missouri | Hotline Healthcare Inspection | ||
1 The Harry S. Truman Memorial Veterans’ Hospital Director strengthens the processes for collaboration between Inpatient Mental Health Unit staff and Vet Center providers for shared patients including for collateral information and discharge planning.
Closure Date:
2 The Harry S. Truman Memorial Veterans’ Hospital Director ensures that Inpatient Mental Health Unit staff collaboratively develop safety plans with patients, including asking the patient directly about access to lethal means.
Closure Date:
3 The Harry S. Truman Memorial Veterans’ Hospital Director continues to monitor the communication of suicide risk assessment results in the hand-off process across clinical settings and takes action as necessary.
Closure Date:
4 The Harry S. Truman Memorial Veterans’ Hospital Director monitors compliance with Mental Health Treatment Coordinator standard operating procedures to ensure that Inpatient Mental Health Unit staff assign a Mental Health Treatment Coordinator, as required.
Closure Date:
5 The Harry S. Truman Memorial Veterans’ Hospital Director ensures that issue briefs are comprehensive and accurate.
Closure Date:
6 The Harry S. Truman Memorial Veterans’ Hospital Director conducts a full review of the patient’s final episode of care and determines whether an institutional disclosure is warranted.
Closure Date:
7 The Under Secretary for Health disseminates written guidance broadly to Veterans Health Administration stakeholders to ensure that Vet Center staff are included in the root cause analysis process for suicide-related events of shared patients.
Closure Date:
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| 20-02774-26 | Added Measures Could Reduce Veterans’ Risk of COVID-19 Exposure in Transitional Housing | Review | ||
1 Issue guidance to medical facility staff on how the COVID 19 At Risk Veteran Report should be used to help service providers identify high risk veterans and educate those veterans on the need for extra precautions.
Closure Date:
2 Ensure medical facility staff are monitoring and assisting with the service providers’ implementation of the Centers for Disease Control and Prevention guidance, including updates.
Closure Date:
3 Identify service providers that have not fully implemented the Centers for Disease Control and Prevention’s six feet social distancing guidelines, particularly for sleeping and meal areas, and encourage them to implement alternative measures or use VA options to help mitigate space limitations.
Closure Date:
4 Monitor the availability of personal protective equipment at service providers’ residences, and help develop contingency plans in the event of a prolonged pandemic or surge.
Closure Date:
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| 20-00132-28 | Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center in Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Quality, Safety, Value, and Innovation Council monitors implemented improvement actions.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths that occur within 24 hours of admission 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 and are properly documented in the VHA Patient Safety Information System.
Closure Date:
4 The Medical Center Director determines the reasons for noncompliance and ensures the Patient Safety Manager or designee provides feedback to staff who submit patient safety incidents that result in a root cause analysis.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals’ departure from the medical center.
Closure Date:
6 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the Chief of Police conducts a physical security evaluation of the Emergency Department.
Closure Date:
7 The Assistant Director determines the reasons for noncompliance and ensures signage is in place for all areas where biohazards are present.
Closure Date:
8 The Assistant Director determines the reasons for noncompliance and ensures that occupational exposure to hazardous materials is minimized in decontamination areas.
Closure Date:
9 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that a safe and clean environment is maintained throughout the Athens VA Clinic.
Closure Date:
10 The Associate Director determines the reasons for noncompliance and ensures that the medication room and housekeeping supply closet at the Athens VA Clinic are secured at all times.
Closure Date:
11 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that personally identifiable information is protected at the Athens VA Clinic.
Closure Date:
12 The Chief of Staff determines the reasons for noncompliance and ensures that policies and procedures are in place for 24 hours a day, 7 days per week gynecological care.
Closure Date:
13 The Chief of Staff determines the reasons for noncompliance and makes certain that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when only one designated provider is available.
Closure Date:
14 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures the medical center has a designated women’s health clinical liaison at each community-based outpatient clinic.
Closure Date:
15 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ instructions for use.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
17 The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and make certain that the Sterile Processing Services staff properly store high-level disinfected endoscopes.
Closure Date:
18 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new employees complete Level 1 training within 90 days of hire.
Closure Date:
19 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Sterile Processing Services staff receive properly completed competency assessments prior to reprocessing reusable medical equipment.
Closure Date:
20 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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15039