Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-00130-06 | Comprehensive Healthcare Inspection of the Carl Vinson VA Medical Center in Dublin, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are developed and documented in the Quality Executive Board
Closure Date:
2 The Chief of Staff determines the reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in practitioner profiles.
Closure Date:
3 The Chief of Staff determines the reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
Closure Date:
4 The Chief of Staff 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:
5 The Chief of Staff determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that nonclinical staff receive the required Operation S.A.V.E. training during new employee orientation.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers complete and document goals of care conversations prior to hospice referrals.
Closure Date:
8 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.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required core members are assigned to and consistently attend Women Veterans Health Committee meetings.
Closure Date:
10 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief maintains an accurate file for all reusable medical equipment that includes the current manufacturers’ instructions for use.
Closure Date:
11 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’ instructions for use, are reviewed at least every three years, and are updated when there is a change.
Closure Date:
12 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:
13 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that written records of weekly eyewash station testing are maintained.
Closure Date:
14 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and certifies that Sterile Processing Services staff complete and document liquid disinfectant solution testing to ensure the minimum effective concentration of the active ingredient is achieved.
Closure Date:
15 The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that annual airflow testing is conducted in the Gastroenterology Sterile Processing Services storage room.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and verifies that eating, drinking, and food item storage is prohibited where the processes of decontamination, sterilization, or clean and sterile storage are performed.
Closure Date:
17 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Closure Date:
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| 20-00132-04 | Comprehensive Healthcare Inspection of the Ralph H. Johnson VA Medical Center in Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines the reasons for noncompliance and ensures that peer reviewers consistently use at least one of the nine aspects of care for evaluations.
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 focused and ongoing professional practice evaluations.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum nuclear medicine-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
4 The Chief of Staff determines the reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
5 The Chief of Staff evaluates and determines any 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 continuation of privileges.
Closure Date:
6 The Medical Center Director determines the 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:
7 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and makes certain that flooring in the inpatient behavioral health unit seclusion room is made of material that provides cushioning.
Closure Date:
8 The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that managers maintain a safe and clean environment.
Closure Date:
9 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures employees complete suicide risk and intervention training within 90 days of entering their position and annual training thereafter.
Closure Date:
10 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.
Closure Date:
11 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee reports to executive leaders and is comprised of required core members who consistently attend meetings.
Closure Date:
12 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the medical center has a designated maternity care coordinator.
Closure Date:
13 The Associate Director for Nursing and Patient Care Services determines the reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is stored.
Closure Date:
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| 20-01326-08 | Management of the Ophthalmology Clinic and Patient Safety Reporting Concerns at the VA Central Iowa Health Care System in Des Moines | Hotline Healthcare Inspection | ||
1 The VA Central Iowa Health Care System Director ensures Ophthalmology Clinic staff are trained on how to identify, analyze, and report patient safety events and close calls.
Closure Date:
2 The VA Central Iowa Health Care System Director ensures that patient safety events and close calls are entered into the Joint Patient Safety Reporting system, and monitors for compliance.
Closure Date:
3 The VA Central Iowa Health Care System Director develops an action plan to address the culture within the Ophthalmology Clinic and monitors effectiveness.
Closure Date:
4 The VA Central Iowa Health Care System Director reviews the oversight and management of the Ophthalmology Clinic, makes recommendations for improvement, and monitors effectiveness.
Closure Date:
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| 19-08106-273 | Deficiencies in Care and Excessive Use of Restraints for a Patient Who Died at the Charlie Norwood VA Medical Center in Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and determines whether an institutional disclosure is warranted.
Closure Date:
2 The Charlie Norwood VA Medical Center Director conducts a full review of the patient’s final episode of care and consults with the appropriate Human Resources and General Counsel Offices to determine whether any personnel actions are warranted.
Closure Date:
3 The Charlie Norwood VA Medical Center Director ensures Emergency Department and Inpatient Medical Unit staff performs vital sign assessment and monitors patients who received sedating medications.
Closure Date:
4 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nurses accurately document medication administration.
Closure Date:
5 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit staff implement patient restraint management according to the Charlie Norwood VA Medical Center policy, including documentation, physician orders, and education requirements.
Closure Date:
6 The Charlie Norwood VA Medical Center Director ensures Intensive Care Unit nursing staff communicate with providers regarding patients’ refusal of treatment.
Closure Date:
7 The Charlie Norwood VA Medical Center Director strengthens Inpatient Medical Unit nicotine replacement therapy processes and monitors compliance.
Closure Date:
8 The Charlie Norwood VA Medical Center Director strengthens processes to include the patient, family members, or surrogate in informed consent procedures and treatment decisions, as appropriate, and monitors compliance.
Closure Date:
9 The Charlie Norwood VA Medical Center Director evaluates the inpatient mental health consult process, and addresses timeliness and completion of decision-making capacity consult requests, and monitors compliance.
Closure Date:
10 The Charlie Norwood VA Medical Center Director consults with the Office of General Counsel regarding policies related to the management of patients presenting under a Form 1013 and advises policy and practices consistent with Georgia State mental health laws and takes action, as appropriate.
Closure Date:
11 The Charlie Norwood VA Medical Center Director ensures staff adhere to inter-facility transfer policies and procedures, including accurate communication of patients’ restraint management status, and monitors compliance.
Closure Date:
12 The Charlie Norwood VA Medical Center Director ensures that a consultation liaison psychiatrist is included on code gray teams at both divisions.
Closure Date:
13 The Charlie Norwood VA Medical Center Director evaluates inpatient mental health consult staffing and establishes a plan to ensure adequate staffing to complete consult requests as required without outpatient mental health appointment cancellations and monitors compliance.
Closure Date:
14 The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
Closure Date:
15 The Charlie Norwood VA Medical Center Director establishes consistent urgency levels in the applicable Charlie Norwood VA Medical Center policies and the corresponding mental health consult template.
Closure Date:
16 The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee reviews patient record flags and provides input into patients’ management to mitigate violence, as required by Veterans Health Administration, and monitors compliance.
Closure Date:
17 The Charlie Norwood VA Medical Center Director makes certain that staff receive education in code gray policy and procedures, including completion of the code gray evaluation form, and monitors compliance.
Closure Date:
18 The Charlie Norwood VA Medical Center Director ensures that the Disruptive Behavior Committee provides oversight of the code gray team activities, as required by Charlie Norwood VA Medical Center policy, and monitors compliance.
Closure Date:
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| 18-04150-261 | VA’s Noncompliance with Preaward Review Requirements for Sole-Source Proposals for Healthcare Services | Review | ||
1 The OIG recommends the VHA executive director for procurement ensures contracting officers are requesting preaward reviews for all sole source healthcare resource contracts with an annual value at or above $400,000 in keeping with the May 2018 revisions to VA Directive 1663.
Closure Date:
2 The OIG recommends the VHA executive director for procurement require an OIG preaward review for all interim contracts that exceed the $400,000 annual threshold.
3 The OIG recommends the VHA executive director for procurement mandate an immediate postaward review for any sole source contract awarded on an interim basis as an emergency contract.
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| 19-00226-245 | Lack of Adequate Controls for Choice Payments Processed through the Plexis Claims Manager System | Audit | ||
1 The OIG recommended the VA deputy under secretary for health for the Office of Community Care Define the terms “verifiable usual and customary charges that are billed to payers other than VA” for the PC3/Choice contract claims.
Closure Date:
2 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure future community care programs have applicable definitions and guidance for claims without a Medicare or VA fee schedule rate to avoid reimbursements that pay at “billed charges.”
Closure Date:
3 The OIG recommended the VA deputy under secretary for health for the Office of Community Care create a master usual and customary rate schedule to be used for reimbursement of community care claims without a Medicare or VA fee schedule rate to control program costs.
Closure Date:
4 The OIG recommended the VA deputy under secretary for health for the Office of Community Care provide parties responsible for reimbursing PC3/Choice and future community care program claims with usual and customary rate price schedules and a formal written policy on the proper application of those rates.
Closure Date:
5 The OIG recommended the VA deputy under secretary for health for the Office of Community Care establish controls for verifiable usual and customary rate payment methodology and establish a payment review process to ensure usual and customary rates are properly applied to the PC3/Choice and future community care program payments.
Closure Date:
6 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure payment-rate schedules used by the Plexis Claims Manager and future payment systems to support the PC3/Choice and future community care contracts are current, accurate, and complete to prevent overpayments.
Closure Date:
7 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure that the Office of Community Care determines an appropriate reimbursement process for the identified pass-through errors in this report.
Closure Date:
8 The OIG recommended the VA deputy under secretary for health for the Office of Community Care ensure the Office of Community Care establishes formal policies and procedures to identify and recover overpayments from PC3/Choice third-party administrators for improperly billed claims.
Closure Date:
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| 20-00005-271 | Nurse Staffing, Patient Safety, and Environment of Care Concerns at the Community Living Center within the San Francisco VA Health Care System in California | Hotline Healthcare Inspection | ||
1 The San Francisco VA Health Care System Director ensures that the Associate Director for Patient Care Services performs a comprehensive review of Community Living Center nurse staffing methodology, retrains the Nurse Staffing Methodology Coordinator, and develops staffing methodology processes that reflect the needs of the Community Living Center.
Closure Date:
2 The San Francisco VA Health Care System Director continues efforts to recruit and hire for Community Living Center nursing assistants and ensures that alternate staffing strategies are consistently available to meet target nursing hours per patient day until optimal staffing is attained.
Closure Date:
3 The San Francisco VA Health Care System Director confers with facility nursing leadership and the Office of Human Resource Management to identify and mitigate barriers to nursing assistant staff retention and recruitment and takes appropriate action.
Closure Date:
4 The San Francisco VA Health Care System Director consults with VA Sierra Pacific Network and VA Central Office to determine the number and status of approved Community Living Center operating beds and takes action as appropriate.
Closure Date:
5 The San Francisco VA Health Care System Director ensures a review of the episode of care related to Resident B’s elopement to determine if a formal quality management review is needed and takes action accordingly.
Closure Date:
6 The San Francisco VA Health Care System Director evaluates the requirement for Community Living Center registry nursing assistant staff access to the electronic health record system, involving the Office of General Counsel and the Network Contracting Office 21 as appropriate and takes action if needed.
Closure Date:
7 The San Francisco VA Health Care System Director ensures that Environmental Management Services provides Community Living Center staff a clear communication pathway to request assistance for all shifts and confirms its functionality.
Closure Date:
8 The San Francisco VA Health Care System Director establishes comprehensive quality monitoring of the ongoing issue of the presence of flying insects in the Community Living Center, and monitors compliance.
Closure Date:
9 The San Francisco VA Health Care System Director ensures that Community Living Center staff adhere to Veterans Health Administration hand-hygiene policies and ensures that corrective actions are initiated when hand-hygiene performance falls below established thresholds.
Closure Date:
10 The San Francisco VA Health Care System Director ensures a comprehensive review of the registry agency agreement for performance, the provision of nursing assistants as requested, and determines if the agreement meets the needs of the Community Living Center.
Closure Date:
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| 19-07062-255 | Greater Consistency Study Participation and Use of Results Could Improve Claims Processing Nationwide | Review | ||
1 The under secretary for benefits directs the Compensation Service to provide the Administration Results Report for each consistency study to the Office of Field Operations and to managers at all regional offices.
Closure Date:
2 The under secretary for benefits ensures the Office of Field Operations develops a process to monitor regional offices to ensure maximum employee participation in consistency studies.
Closure Date:
3 The under secretary for benefits makes certain the Office of Field Operations establishes a requirement for regional office managers to review consistency study results and develop a plan for corrective action based on the performance of their regional office.
Closure Date:
4 The under secretary for benefits requires the Office of Field Operations to develop a follow-up process to confirm all corrective actions identified are completed by regional office managers.
Closure Date:
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| 19-07854-272 | Deficiencies in Pharmacy and Nursing Processes at the Southeast Louisiana Veterans Health Care System in New Orleans | Hotline Healthcare Inspection | ||
1 The Southeast Louisiana Veterans Health Care System Director educates pharmacy staff on the Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies related to unaffixed medication labels, and monitors compliance.
Closure Date:
2 The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff comply with the five rights of medication administration prior to administering medications.
Closure Date:
3 The Southeast Louisiana Veterans Health Care System Director ensures that the intensive care unit nursing staff administer medications in accordance with physician orders as required by Veterans Health Administration and Southeast Louisiana Veterans Health Care System policies.
Closure Date:
4 The Southeast Louisiana Veterans Health Care System Director confirms that the intensive care unit nursing staff comply with the Southeast Louisiana Veterans Health Care System policy for high-alert and high-risk medications.
Closure Date:
5 The Southeast Louisiana Veterans Health Care System Director validates compliance with obtaining locked boxes to secure controlled substances for intravenous medications administered on the inpatient units.
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6 The Southeast Louisiana Veterans Health Care System Director verifies that facility staff are aware of how to submit Joint Patient Safety Reports that contain complete and accurate information.
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7 The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if peer reviews of relevant clinical staff are warranted.
Closure Date:
8 The Southeast Louisiana Veterans Health Care System Director evaluates the circumstances surrounding the death of the patient and determines if an institutional disclosure is warranted.
Closure Date:
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| 19-07828-265 | Deficiencies in Provider Oversight and Privileging Processes at the Carl Vinson VA Medical Center in Dublin, Georgia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with the oversight of medical staff, including those with possible physical impairments.
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2 The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with privileging policies.
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3 The Veterans Integrated Service Network 7 Director ensures Carl Vinson VA Medical Center leaders, in permanent or acting roles, are knowledgeable about and compliant with state licensing board reporting policies.
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4 The Carl Vinson VA Medical Center Director evaluates concerns that the urologist has a possible physical impairment, consults with Human Resources, and takes action, if indicated.
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5 The Carl Vinson VA Medical Center Director reviews current clinical care review processes, identifies areas of noncompliance with facility bylaws, and takes action to ensure compliance.
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6 The Carl Vinson VA Medical Center Director reviews current reduction of privileges processes, identifies areas of noncompliance, and takes action to ensure compliance with Veterans Health Administration policy.
Closure Date:
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15039