Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 20-02794-218 | Appointment Management During the COVID-19 Pandemic | Review | ||
1 The OIG recommended the under secretary for health develop and clearly communicate a well defined strategic plan to all medical facilities for rescheduling patients and provide oversight particularly to those facilities with the highest rates of canceled appointments with no evidence of follow up or tracking.
Closure Date:
2 The OIG recommended the under secretary for health develop a mechanism to monitor facilities’ progress with following up on all cancellations to ensure facilities are not solely relying on COVID annotations or cancellation source classifications when rescheduling.
Closure Date:
3 The OIG recommended the under secretary for health ensure that facilities take appropriate follow up action on canceled or discontinued consults.
Closure Date:
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| 20-00064-238 | Comprehensive Healthcare Inspection of the Captain James A. Lovell Federal Health Care Center in North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures improvement action items recommended by the Quality Council are fully implemented and monitored.
Closure Date:
2 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain the Patient Flow Committee meeting minutes reflect documentation, implementation, and evaluation of action items.
Closure Date:
3 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
Closure Date:
4 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures service chiefs document focused professional practice evaluation results in provider profiles.
Closure Date:
5 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of initially granted privileges.
Closure Date:
6 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation criteria.
Closure Date:
7 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures that providers with similar training and privileges complete licensed independent practitioners’ ongoing professional practice evaluations.
Closure Date:
8 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review form within seven calendar days of the professional’s departure from the center.
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9 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers repair or remove damaged wheelchairs from service.
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10 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that healthcare center managers maintain a safe and clean environment.
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11 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures adequate privacy is provided in patient examination rooms at the Evanston VA Clinic.
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12 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures the information technology room at the Evanston VA Clinic is secure and restricted to authorized personnel.
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13 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions.
Closure Date:
14 The Healthcare Center Director determines the reasons for noncompliance and ensures clinical and nonclinical staff complete annual suicide prevention refresher training.
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15 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and ensures that clinicians at community-based outpatient clinics provide integrated mental health services for women veterans.
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16 The Healthcare Center Director evaluates and determines any additional 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 clinics have only one provider.
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17 The Healthcare Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings.
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18 The Chief Medical Executive evaluates and determines any additional reasons for noncompliance and ensures the Women’s Health Medical Director collects, tracks, and reports quality assurance data.
Closure Date:
19 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services aligns standard operating procedures with manufacturers’ guidelines and instructions for use.
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20 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services enters all equipment into the CensiTrac® Instrument Tracking System.
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21 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that the Chief of Sterile Processing Services consistently reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
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22 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff conduct annual airflow testing in all areas where reusable medical equipment is reprocessed or stored.
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23 The Associate Director for Facilities Support evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Engineering Service or designee conduct and maintain the record of weekly eyewash station function testing.
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24 The Associate Director for Facilities Support determines the reasons for noncompliance and makes certain the Environmental Management Supervisor develop, implement, and enforce a written cleaning schedule for all Sterile Processing Services areas.
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25 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that endoscopes are properly stored by Sterile Processing Services and clinical staff.
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26 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
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27 The VA Chief Nurse Executive evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services staff receive monthly continuing education.
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| 20-02240-248 | Alleged Deficiencies in the Management of Staff Exposure to a Patient with COVID-19 at the VA Portland Health Care System in Oregon | Hotline Healthcare Inspection | ||
1 The Portland VA Health Care System Director ensures that a consistent notification process is implemented and monitored to ensure the sending department notifies the receiving department of a patient’s potential infectious disease status prior to transfer and verifies appropriate infection control precautions are implemented prior to transfer.
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2 The Portland VA Health Care System Director ensures that the standard process for contact tracing for staff exposure to high-consequence infections such as COVID-19 includes a process for identification of potentially exposed staff who cannot be identified through electronic health record documentation.
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3 The Portland VA Health Care System Director ensures that standard processes for assessment of staff exposure to high-consequence infections such as COVID-19, including a process for validation of supervisors’ initial risk categorizations, are implemented and monitored to support reliable and accurate exposure risk categorization.
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4 The Portland VA Health Care System Director ensures that standard processes are implemented and monitored for tracking staff exposure, providing guidance on self-monitoring, self-quarantine, and returning to work, and documenting Employee Health Service contacts with exposed employees.
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5 The Portland VA Health Care System Director ensures facility policies are reviewed and updated to include a detailed staff exposure management process to leverage lessons learned from the current pandemic response and to enhance preparedness for future events.
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| 20-00075-225 | Comprehensive Healthcare Inspection of the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are documented in Quality Management Oversight Committee minutes when problems or opportunities for improvement are identified.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database.
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3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives are assigned and consistently participate in interdisciplinary reviews of utilization management data.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document criteria in practitioner profiles for focused professional practice evaluations.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate, complete, and document the results of focused professional practice evaluations in practitioner profiles.
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6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all focused professional practice evaluations include defined time frames.
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7 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:
8 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures service chiefs consistently collect and review ongoing professional practice evaluation data for the determination to recommend continuation of privileges.
Closure Date:
9 The Chief of Staff evaluates and determines additional reasons for noncompliance and ensures that licensed independent practitioners’ ongoing professional practice evaluations are completed by providers with similar training and privileges.
Closure Date:
10 The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that Medical Executive Committee meeting minutes consistently reflect the review of professional practice evaluation results in the decision to recommend continuation of privileges.
Closure Date:
11 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 departing the medical center.
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12 The Assistant Director evaluates and determines any additional reasons for noncompliance and makes sure that biohazardous rooms are not used to store clean items.
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13 The Assistant Director determines the reasons for noncompliance and ensures that clean/sterile storeroom solid-bottom shelves are clean.
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14 The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center and outpatient clinic buildings.
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15 The Associate Director for Patient Care Services evaluates and determines additional reasons for noncompliance and ensures that patient care equipment is clean and ready for use.
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16 The Medical Center Director ensures that Office of Information Technology leaders determine the reasons for noncompliance and ensures that access is controlled to information technology rooms.
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17 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment to include a history of substance abuse and psychological disease on all patients prior to initiating long-term opioid therapy.
Closure Date:
18 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing for patients on long-term opioid therapy.
Closure Date:
19 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers obtain and document informed consent consistently for patients who are initiating long-term opioid therapy.
Closure Date:
20 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within three months and assess adherence to the pain management plan of care and effectiveness of interventions.
Closure Date:
21 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up appointments within the prescribed time frame and include documentation of the patient’s preference for a telephone call, if applicable.
Closure Date:
22 The Chief of Staff determines the reasons for noncompliance and ensures that processes and procedures are in place to ensure gynecological care is available 24 hours a day, 7 days per week.
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23 The Medical Center Director determines the reasons for noncompliance and makes certain that required members are assigned and consistently attend Women Veterans Health Committee meetings and report to executive leaders.
Closure Date:
24 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that required quality assurance data related to women veterans’ health care services are collected and tracked for improvement opportunities.
Closure Date:
25 The Chief of Staff determines the reason(s) for noncompliance and ensures the Women Veterans Program Manager is full-time and free of collateral duties.
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26 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief consistently performs and documents an annual risk analysis and reports the results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
27 The Assistant Director evaluates and determines any additional reasons for noncompliance and ensures that the written cleaning schedule for Sterile Processing Services is enforced.
Closure Date:
28 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that high-level disinfected scopes are stored properly.
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| 20-00069-222 | Comprehensive Healthcare Inspection of the Edward Hines, Jr. VA Hospital in Hines, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures specific action items are monitored and documented in the Quality Board minutes when problems or opportunities are identified.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that all applicable deaths within 24 hours of admission are peer reviewed.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that a summary of the Peer Review Committee’s analyses is reviewed quarterly by the Medical Executive Board.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
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5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs initiate and complete focused professional practice evaluations on all newly hired licensed independent practitioners.
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6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum pathology and radiation oncology specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
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7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures service chiefs collect, review, and use ongoing professional practice evaluation data in determinations to continue current privileges.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decisions to recommend initial and continuation of privileges are based on focused and ongoing professional practice evaluation results.
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 calendar days of licensed healthcare professionals departing the medical center.
Closure Date:
10 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that Sterile Processing Services employees remove expired commercial sterile supplies from service.
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11 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures clinical areas are in good repair and that a safe and clean environment is maintained throughout the medical center.
Closure Date:
12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers complete pain screening for all patients prior to initial dispensing of long-term opioid therapy.
Closure Date:
13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete an aberrant behavior risk assessment on all patients prior to initiating long-term opioid therapy.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
Closure Date:
16 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that follow-up with patients receiving long-term opioid therapy include an assessment of adherence to the pain management plan of care and the effectiveness of the intervention.
Closure Date:
17 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures staff receive annual suicide prevention refresher training.
Closure Date:
18 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that at least 10 percent of reprocessed endoscopes are tested for bioburden.
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19 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that traffic flow in the gastroenterology clean storage area is restricted.
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20 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services maintains required climate control parameters for areas where reusable medical equipment is reprocessed and stored.
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21 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff complete Level 1 training within 90 days of hire
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22 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Sterile Processing Services Chief complete competency assessments for staff reprocessing reusable medical equipment.
Closure Date:
23 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 19-09669-236 | Inadequate Inpatient Psychiatry Staffing and Noncompliance with Inpatient Mental Health Levels of Care at the VA Central Western Massachusetts Healthcare System in Leeds | Hotline Healthcare Inspection | ||
1 The VA Central Western Massachusetts Healthcare System Director ensures adequate psychiatry staffing to afford providers adequate time for direct patient care on the acute and subacute inpatient mental health units.
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2 The VA Central Western Massachusetts Healthcare System Director provides ongoing monitoring and evaluation of acute and subacute unit medical provider staffing.
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3 The VA Central Western Massachusetts Healthcare System Director ensures that the utilization management plan accurately reflects and is compliant with all Veterans Health Administration requirements.
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4 The VA Central Western Massachusetts Healthcare System Director makes certain medical officers on duty complete inpatient mental health admission medical clearance assessments in accordance with Central Western Massachusetts Healthcare System and Veterans Health Administration policies.
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5 The VA Central Western Massachusetts Healthcare System Director makes certain that recovery-oriented programming occurs as scheduled and consists of at least four hours per day.
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6 The VA New England Health Care System Director develops business plans for restructuring of clinical programs to include transitioning sustained treatment and rehabilitation beds, subacute unit beds, and specialized inpatient posttraumatic stress disorder beds as required by the Veterans Health Administration.
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7 The VA Central Western Massachusetts Healthcare System Director consults with Veterans Integrated Service Network 1 leaders to determine and implement a process to monitor clinical appropriateness for patients in all inpatient mental health beds, including sustained treatment and rehabilitation beds until restructuring of clinical programs is complete.
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| 19-06848-209 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 15: VA Heartland Network in Kansas City, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that annual utilization management program summary reviews are completed for each facility.
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2 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact submits an annual Pain Management Strategy implementation and progress report.
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3 The Network Director determines the reason for noncompliance and ensures the Veterans Integrated Service Network-level pain management point of contact establishes a pain committee
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4 The Network Director determines the reasons for noncompliance and makes certain that the lead Women Veterans Program Manager executes interdisciplinary strategic planning activities for comprehensive women’s health care.
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5 The Chief Medical Officer evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager provides quarterly updates to the Network Director or Chief Medical Officer.
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6 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager conducts yearly site visits at each facility within the Veterans Integrated Service Network.
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7 The Network Director evaluates and determines any additional reasons for noncompliance and ensures that the lead Women Veterans Program Manager develops educational programs and/or resources for needs identified from the staff education gap assessment
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8 The Network Director evaluates and determines any additional reasons for noncompliance and makes certain that the lead Women Veterans Program Manager analyzes women veterans’ access and satisfaction data.
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9 The Network Director evaluates and determines any additional reasons for noncompliance and ensures the lead Women Veterans Program Manager tracks maternity care outcome data.
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10 The Network Director determines the reasons for noncompliance and ensures that facility corrective action plans are developed and submitted within 30 days of each completed inspection.
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| 19-06872-199 | Comprehensive Healthcare Inspection of the Robert J. Dole VA Medical Center in Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures all required representatives consistently participate in interdisciplinary reviews of utilization management data.
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2 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analyses include all required review elements and are properly documented in the VHA Patient Safety Information System.
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3 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that root cause analysis actions are implemented and properly documented in the VHA Patient Safety Information System.
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4 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that the Patient Safety Manager or designee provides an annual patient safety report to medical center leaders.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in provider profiles.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that reprivileging decisions are based on service-specific ongoing professional practice evaluation data.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures clinical managers consistently collect and review ongoing professional practice evaluation data.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that Medical Professional Standards Board meeting minutes consistently reflect the review of professional practice evaluation results when recommending continuation of privileges.
Closure Date:
10 The Chief of Staff determines reason(s) for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
Closure Date:
11 The Chief of Staff determines reason(s) for noncompliance and ensures the departing licensed healthcare professional’s first- or second-line supervisor appropriately signs the exit review form.
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12 The Associate Director determines reason(s) for noncompliance and ensures that patient care supply areas are properly designated, and adequate temperature and humidity controls are continuously monitored and maintained.
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13 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures that a safe and clean environment is maintained throughout the medical center.
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14 The Chief of Staff determines the reason(s) for noncompliance and ensures that personally identifiable information is protected when transporting information or specimens from the clinics to the medical center.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on patients prior to initiating long-term opioid therapy.
Closure Date:
16 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients who are initiating long-term opioid therapy.
Closure Date:
17 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy.
Closure Date:
18 The Chief of Staff determines reason(s) for noncompliance and makes certain that clinicians conduct four follow-up appointments within the required time frame and document the patient’s preference for telephonic follow-up, if warranted.
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19 The Chief of Staff evaluates and determines any additional reason(s) for noncompliance and ensures that clinicians complete safety plans in a timely manner and that all required elements—including firearm and opioid safety—are assessed for patients with High Risk for Suicide Patient Record Flags.
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20 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and ensures clinical and nonclinical staff receive annual suicide prevention refresher training.
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21 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and appoints a multidisciplinary committee responsible for life-sustaining treatment decision reviews that includes representatives from three or more different disciplines.
Closure Date:
22 The Medical Center Director evaluates and determines any additional reason(s) for noncompliance and makes certain that required members consistently attend Women Veterans Health Committee meetings.
Closure Date:
23 The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and makes certain that Sterile Processing Services reports the annual risk analysis to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
24 The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that Sterile Processing Services maintain required airflow parameters for areas where reusable medical equipment is reprocessed.
Closure Date:
25 The Associate Director for Patient Care Services evaluates and determines any additional reason(s) for noncompliance and ensures that staff avoid eating, drinking, and/or storing food items in areas where decontamination, sterilization, or clean/sterile storage occurs.148
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26 The Associate Director for Patient Care Services determines reason(s) for noncompliance and ensures that staff properly store endoscopes.
Closure Date:
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| 19-07062-230 | Site Visit Program Can Do More to Improve Nationwide Claims Processing | Review | ||
1 The OIG recommended that the under secretary for benefits direct the Compensation Service to formalize the Hot Topics list into an annual report submitted to the Office of Field Operations detailing all recurring deficiencies and action items identified throughout the inspection year from its site visit program.
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2 The OIG recommended that the under secretary for benefits require the Office of Field Operations to initiate a recurring plan to correct all recurring deficiencies and action items identified by the Compensation Service throughout the inspection year from its site visit program annual report.
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3 The OIG recommended that the under secretary for benefits direct the Office of Field Operations to establish a follow-up process to monitor compliance with the new requirement and hold regional office managers accountable for making corrections and addressing action items in a timely manner.
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| 20-00077-211 | Comprehensive Healthcare Inspection of the Jesse Brown VA Medical Center in Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a minimum of 80 percent of inpatient utilization management reviews are completed.
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2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all required representatives consistently participate in interdisciplinary utilization management data reviews.
Closure Date:
3 The Chief of Staff evaluates and determines additional reasons for noncompliance and makes certain that the Medical Executive Council documents conclusions and recommendations for continuation of privileges that are based on focused professional practice evaluation results.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that first- or second-line supervisors complete provider exit review forms within seven calendar days of providers’ departure from the medical center.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that service leaders immediately report a provider’s failure to meet generally accepted standards of practice to state licensing boards
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete an aberrant behavior risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
Closure Date:
7 The Chief of Staff determines the reasons for noncompliance and makes certain that clinicians document justification for concurrent opioid and benzodiazepine medication therapy.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians consistently obtain and document informed consent for patients prior to initiating long-term opioid therapy.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians follow up with patients within the required time frame after initiating long-term opioid therapy.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that provider follow-up with patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.
Closure Date:
12 The Medical Center Director determines the reasons for noncompliance and makes certain that the Pain Committee monitors the quality of pain assessment and effectiveness of pain management interventions.
Closure Date:
13 The Chief of Staff determines the reasons for noncompliance and ensures that mental health providers consistently contact or attempt to contact high-risk patients who miss mental health or substance abuse appointments and properly document those efforts.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and verifies that providers complete safety plans within the required time frame for patients with High Risk for Suicide Patient Record Flags.
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15 The Chief of Staff evaluate and determines any additional reason for noncompliance and makes certain that suicide prevention safety plans include all required elements.
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16 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain staff complete suicide risk and intervention training within 90 days of entering their position and annual suicide prevention refresher training thereafter.
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17 The Medical Center Director determines the reasons for noncompliance and makes certain that a multidisciplinary life-sustaining treatment decisions committee is established to review all proposed plans.
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18 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each site of care 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:
19 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members consistently attend the Women Veterans Health Committee meetings.
Closure Date:
20 The Associate Director for Patient Care Services determines the reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.
Closure Date:
21 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that the Chief of Sterile Processing Services reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
22 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff receive properly completed competency assessments for reprocessing reusable medical equipment.
Closure Date:
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