Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-06873-210 | Comprehensive Healthcare Inspection of the VA St. Louis Health Care System in Missouri | Comprehensive Healthcare Inspection Program | ||
1 The System Director evaluates and determines any additional reasons for noncompliance and ensures improvement actions recommended by the Quality Executive Board are fully implemented and improvement changes are monitored.
Closure Date:
2 The Chief of Staff 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 System Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager or designee consistently implements improvement actions arising from root cause analysis activities.
Closure Date:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs include service-specific criteria for ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that service chiefs’ reprivileging recommendations are based on ongoing professional practice evaluation activities.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Medical Executive Board’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results.
Closure Date:
7 The System 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 healthcare system.
Closure Date:
8 The Associate Director determines the reasons for noncompliance and ensures mental health unit cameras are reconfigured to eliminate blind spots.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavioral risk assessment that includes a history of substance abuse, psychological disease, and aberrant drug-related behaviors for all patients prior to initiating long-term opioid therapy.
Closure Date:
10 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers consistently obtain and document informed consent for patients prior to beginning long-term opioid therapy.
Closure Date:
12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within three months after initiating long-term opioid therapy and assess intervention effectiveness.
Closure Date:
13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that the Pain Committee monitors the quality of pain assessment, effectiveness of pain management interventions, and opportunities for improvements.
Closure Date:
14 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Suicide Prevention Coordinator delivers at least five outreach activities each month.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic with documented consent, within the required time frame.
Closure Date:
16 The System Director evaluates and determines any additional reasons for noncompliance and ensures staff receive annual suicide prevention refresher training.
Closure Date:
17 The System 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 and that the committee reports to an executive leadership board.
Closure Date:
18 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that gastroenterology staff test at least 10 percent of reprocessed endoscopes for bioburden and testing to include each endoscope model.
Closure Date:
19 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that all new Sterile Processing Services employees complete Level 1 training within 90 days of hire.
Closure Date:
20 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 20-01129-220 | Improving VA and Select Community Care Health Information Exchanges | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health reviews the barriers related to the utilization of VA Direct and ensures the Veterans Health Information Exchange Program Office increases the number of facilities using VA Direct as a secure option to share health information.
Closure Date:
2 The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office evaluates the VA Exchange and VA Direct training and education programs and increases accessibility to Veterans Health Administration staff, community partners, and veterans.
Closure Date:
3 The Under Secretary for Health ensures the Veterans Health Information Exchange Program Office increases the number of community partners, including more state exchanges and other Health Information Exchange stakeholders, to facilitate the expansion of bidirectional health information exchange.
Closure Date:
4 The Under Secretary for Health confirms the Veterans Health Information Exchange Program Office evaluates the performance work statements of the Veterans Health Information Exchange community coordinators and ensures compliance with the scope of work.
Closure Date:
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| 19-08666-212 | Surrogate Decision-Maker, Clinical, and Patient Rights Deficiencies at the Robley Rex VA Medical Center in Louisville, Kentucky | Hotline Healthcare Inspection | ||
1 The Robley Rex VA Medical Center Director ensures staff document clinical assessments of patients’ decision-making capacity throughout hospitalization as required by Veterans Health Administration policy.
Closure Date:
2 The Robley Rex VA Medical Center Director evaluates social worker practices related to facilitating the release of information when a patient lacks decision-making capacity, and takes action as indicated.
Closure Date:
3 The Robley Rex VA Medical Center Director establishes “reasonable inquiry” parameters for determination of a surrogate as required by Veterans Health Administration policy and provides staff education as needed.
Closure Date:
4 The Robley Rex VA Medical Center Director ensures that when patients lack decision-making capacity, staff verify and document the status of surrogates, and the efforts to identify surrogates, according to Veterans Health Administration policy.
Closure Date:
5 The Robley Rex VA Medical Center Director evaluates the quality and comprehensiveness of clinical documentation in support of diagnoses and treatment decisions across the patient’s hospitalization, and takes action as indicated.
Closure Date:
6 The Robley Rex VA Medical Center Director ensures interdisciplinary and cross-service communication and collaboration for complex patients and monitors compliance.
Closure Date:
7 The Robley Rex VA Medical Center Director ensures providers complete medication reconciliation for patients transferred to the mental health unit(s) as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
Closure Date:
8 The Robley Rex VA Medical Center Director ensures compliance regarding completion of documentation of PRN (as needed) medication effectiveness as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
Closure Date:
9 The Robley Rex VA Medical Center Director reviews clinical decision-making and administrative processes relative to the patient’s admission to hospice, and takes appropriate actions as indicated.
Closure Date:
10 The Robley Rex VA Medical Center Director develops a mechanism to ensure involuntary admissions (72-hour holds) for current and future patients are managed and documented according to Veterans Health Administration and Robley Rex VA Medical Center policies, and Kentucky state laws.
Closure Date:
11 The Robley Rex VA Medical Center Director develops a mechanism to ensure that patients in behavioral restraints are assessed every 15 minutes as required, and that documentation complies with Veterans Health Administration policy.
Closure Date:
12 The Robley Rex VA Medical Center Director ensures that its policy on restraints and seclusion is updated to reflect the frequency of training requirements, and that staff are appropriately trained and competent in the use of restraints as required by Veterans Health Administration and Robley Rex VA Medical Center policies.
Closure Date:
13 The Robley Rex VA Medical Center Director takes action to ensure processes for reviewing inpatient deaths is consistent with Veterans Health Administration policy.
Closure Date:
14 The Robley Rex VA Medical Center Director reviews the patient’s continuum of care and evaluates if additional peer reviews and/or other quality reviews are warranted, and takes action as indicated.
Closure Date:
15 The Robley Rex VA Medical Center Director reviews the circumstances related to an unauthorized individual making decisions for the patient and conducts appropriate disclosure to the patient’s representative as warranted.
Closure Date:
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| 19-08095-198 | Accuracy of Disability Benefit Evaluations for Veterans' Service-Connected Heart Diseases | Review | ||
1 We recommended the under secretary for benefits implement a plan to incorporate the system-generated instructions for medical providers directly into the heart disability questionnaire (instead of separately on the examination request) and determine whether additional revisions are necessary to ensure medical providers’ findings are sufficient for evaluation purposes.
Closure Date:
2 We recommended the under secretary for benefits implement a plan to ensure medical providers who complete heart disability benefits questionnaires are made aware of common problem areas related to the questionnaire format and system-generated instructions and are provided guidance on how to avoid giving conflicting or insufficient information.
Closure Date:
3 We recommended the under secretary for benefits implement a plan to make certain that Veterans Benefits Administration decision makers receive refresher training on identifying and resolving heart disability benefits questionnaires that are insufficient for evaluation purposes and monitor the effectiveness of the training.
Closure Date:
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| 20-00068-206 | Comprehensive Healthcare Inspection of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures implementation of specific action items are documented in Quality Council minutes 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 all required representatives are assigned and consistently participate in interdisciplinary reviews of utilization management data.
Closure Date:
3 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs include the minimum required gastroenterology-specific criteria for focused and ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
4 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:
5 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures all medical equipment is identified as safe for patient use.
Closure Date:
6 The Associate Director evaluates and determines any additional reasons for noncompliance and makes certain that staff remove expired medications from patient care areas.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers 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:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that healthcare providers 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 healthcare providers 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 healthcare providers follow up with patients within three months after initiating long-term opioid therapy to assess adherence to the therapy plan and effectiveness of treatment.
Closure Date:
11 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that employees receive initial suicide prevention training within 90 days of hire and annual refresher training thereafter.
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 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 traffic flow in the Gastroenterology clean storage areas is restricted.
Closure Date:
14 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that temperature and humidity requirements are maintained and documented for the Gastroenterology clean storage areas.
Closure Date:
15 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services staff receive competency assessments prior to reprocessing reusable medical equipment.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures Sterile Processing Services staff receive monthly continuing education.
Closure Date:
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| 19-09776-223 | Alleged Deficiencies in Pharmacy Service Procedures at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia | Hotline Healthcare Inspection | ||
1 The Louis A. Johnson VA Medical Center Director ensures implementation of a process to document and track orientation, competency assessment, and annual competencies of pharmacy staff, and monitors compliance.
Closure Date:
2 The Louis A. Johnson VA Medical Center Director ensures facility leaders are trained in the process of reporting any and all future diversions and loss incidents according to requirements outlined in VHA Directive 1108.01, Controlled Substance Management, May 1, 2019.
Closure Date:
3 The Louis A. Johnson VA Medical Center Director conducts a review of the circumstances that resulted in the misplacement of testosterone and develops an action plan to prevent a similar recurrence, if warranted.
Closure Date:
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| 19-09486-204 | Focused Performance Review of Select Metrics at the Ioannis A. Lougaris VA Medical Center in Reno, Nevada | Hotline Healthcare Inspection | ||
1 The Ioannis A. Lougaris VA Medical Center Director ensures mechanisms to report and follow up on performance deficits are well-defined and disseminated to staff and monitors to confirm functionality.
Closure Date:
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| 19-07600-215 | Facility Oversight and Leaders’ Responses Related to the Deficient Practice of a Pathologist at the Hunter Holmes McGuire VA Medical Center in Richmond, Virginia | Hotline Healthcare Inspection | ||
1 The Hunter Holmes McGuire VA Medical Center Director ensures that the Pathology and Laboratory Medicine Services actionable supplemental test results are communicated timely in accordance with Veterans Health Administration policy.
Closure Date:
2 The Hunter Holmes McGuire VA Medical Center Director ensures that facility leaders adhere to Veterans Health Administration policy that outlines the processes for the disclosure of adverse events, including clinical and institutional disclosures.
Closure Date:
3 The Hunter Holmes McGuire VA Medical Center Director reviews the treatment course for the identified dermatology patient who experienced an adverse clinical outcome and takes action, including disclosures, if appropriate.
Closure Date:
4 The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting of all adverse events to the patient safety manager.
Closure Date:
5 The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to reporting adverse events to the VA Pathology Regional Commissioner.
Closure Date:
6 The Hunter Holmes McGuire VA Medical Center Director ensures staff compliance with Veterans Health Administration policies related to issue briefs.
Closure Date:
7 The Hunter Holmes McGuire VA Medical Center Director ensures that facility leaders adhere to Veterans Health Administration policy that outlines the summary suspension process for licensed independent practitioners.
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8 The Hunter Holmes McGuire VA Medical Center Director verifies that facility leaders adhere to Veterans Health Administration policy that outlines the credentialing and privileging process as related to the subject pathologist.
Closure Date:
9 The Hunter Holmes McGuire VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for state licensing board reporting.
Closure Date:
10 The Hunter Holmes McGuire VA Medical Center Director ensures that the Pathology and Laboratory Medicine Service Chief ensures the required Veterans Health Administration and facility quality reviews of the Pathology and Laboratory Medicine Services’ pathologists are performed.
Closure Date:
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| 20-00062-205 | Comprehensive Healthcare Inspection of the VA Illiana Health Care System in Danville, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines reasons for noncompliance and makes certain that ongoing professional practice evaluations include service-specific criteria and are completed by providers with similar training and privileges.
Closure Date:
2 The System 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 healthcare system.
Closure Date:
3 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:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for prescribing opioids and benzodiazepines concurrently.
Closure Date:
5 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:
6 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 prior to initiating long-term opioid therapy.
Closure Date:
7 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers conduct four follow-up visits, either face-to-face or telephonic with documented preference within the required time frame.
Closure Date:
8 The System 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.
Closure Date:
9 The System 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:
10 The System Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee holds quarterly meetings with required representatives, and report to executive leaders.
Closure Date:
11 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with current manufacturers’ guidelines and instructions for use.
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 to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
13 The Associate Director for Patient Care Services evaluates and determines additional 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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| 19-07507-214 | Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center | Hotline Healthcare Inspection | ||
1 The Washington DC VA Medical Center Director ensures that Emergency Department staff adhere to Veterans Health Administration suicide prevention policies and monitors compliance.
Closure Date:
2 The Washington DC VA Medical Center Director ensures that patients are adequately assessed for withdrawal risk and provided with appropriate disposition for management of withdrawal.
Closure Date:
3 The Washington DC VA Medical Center Director ensures staff education of the Veterans Health Administration and Washington DC VA Medical Center policies related to employee misconduct and patient abuse, and monitors compliance.
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4 The VA Capitol Health Care Network Director reviews Washington DC VA Medical Center leadership and supervisory response to allegations of employee misconduct and patient abuse to determine if administrative action is warranted and takes action as appropriate.
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5 The Washington DC VA Medical Center Director determines leaders’ authority and duty to report physician 2’s behavior to the State Licensing Board and National Practitioner Data Bank and takes action as indicated.
Closure Date:
6 The Washington DC VA Medical Center Director establishes comprehensive quality monitoring of the required hand-off communication processes, including interdisciplinary participation and monitors compliance.
Closure Date:
7 The Washington DC VA Medical Center Director makes certain that Emergency Department staff reconcile diagnostic and care plan information that may vary across providers and shifts when determining a patient’s final disposition.
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8 The Washington DC VA Medical Center Director ensures that Emergency Department staff include the patient and family members, in the development of a care plan as appropriate, and monitor compliance.
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9 The Washington DC VA Medical Center Director ensures that facility staff complete Suicide Behavior and Overdose reports as required.
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10 The Washington DC VA Medical Center Director establishes quality monitoring of consult scheduling procedures and monitors compliance.
Closure Date:
11 The Washington DC VA Medical Center Director expedites Emergency Department renovations to ensure a safe and secure area for evaluation of mental health patients.
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14957