Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-01781-200 | Allegations of Nepotism at the Miami VA Healthcare System in Florida | Administrative Investigation | ||
1 The Miami VA Health Care System Director determines the appropriate administrative action to take, if any, with respect to the chief nurse’s advocacy in favor of hiring the spouse.
Closure Date:
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| 17-04969-202 | Alleged Misuse of Official Time and Possible Ethics Violation by an Information Technology Employee | Administrative Investigation | ||
1 The employee’s supervisor confers with the Designated Agency Ethics Official and the Office of Human Resources and Administration to determine the appropriate administrative action to take, if any, with respect to the employee’s conduct in connection with the procurement of hotel services from the employer of the spouse.
Closure Date:
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| 20-00513-216 | Alleged Deficiencies within the Cardiac Telemetry Monitoring Service at the Nashville VA Medical Center in Tennessee | Hotline Healthcare Inspection | ||
1 The Tennessee Valley Healthcare System Director ensures consistency between the system’s policy and actual practice for initiation of a rapid response team call.
Closure Date:
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| 19-06850-208 | Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that the Patient Safety Manager submits each root cause analysis to the National Center for Patient Safety within the required time frame.
Closure Date:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define in advance, communicate, and document expectations for focused professional practice evaluations in the providers’ profiles.
Closure Date:
3 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:
4 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Executive Committee of the Medical Staff’s decision to recommend continuation of privileges is based on ongoing professional practice evaluation results.
Closure Date:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that provider exit review forms are completed within seven calendar days of licensed healthcare professionals departing the medical center.
Closure Date:
6 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that nursing staff label multidose medication vials with an expiration date upon opening.
Closure Date:
7 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures that privacy curtains are installed in all examination rooms at the Shawnee VA Clinic.
Closure Date:
8 The Associate Director evaluates and determines any additional reasons for noncompliance and ensures a record of visitor access for the information technology room is maintained at the Shawnee VA Clinic.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians complete a behavior risk assessment that includes a history of substance abuse, mental health problems or disorders, and aberrant drug-related behaviors on 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 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 providers consistently obtain and document informed consent prior to initiating patients on long-term opioid therapy.
Closure Date:
12 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians follow up with patients receiving long-term opioid therapy includes an assessment of adherence to the pain management plan of care.
Closure Date:
13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that the Pain Management Committee monitors the quality of pain assessments and the effectiveness of pain management interventions.
Closure Date:
14 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures all staff receive annual suicide prevention refresher training.
Closure Date:
15 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that a multidisciplinary life-sustaining treatment decisions committee is established to review all proposed plans.
Closure Date:
16 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that the Sterile Processing Services Chief reports the annual risk analysis results to the Veterans Integrated Service Network Sterile Processing Services Management Board.
Closure Date:
17 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that airflow is monitored in the gastroenterology clinic clean scope rooms.
Closure Date:
18 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that damaged flooring or tiles are repaired or replaced in the gastroenterology clean scope storage room.
Closure Date:
19 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that high-level disinfected endoscopes are stored properly.
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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| 19-07059-169 | The Systematic Technical Accuracy Review Program Has Not Adequately Identified and Corrected Claims-Processing Deficiencies | Review | ||
1 Improve the current second-review process for quality reviews when STAR analysts identify claims-processing deficiencies and consider requiring senior reviewers to conduct a comprehensive review of all issues assessed by the analyst.
Closure Date:
2 Establish a formal second-review process for quality reviews when STAR analysts do not identify claims-processing deficiencies.
Closure Date:
3 Assess the current training requirements for STAR staff and establish a formal training plan that promotes claims-processing expertise and accuracy.
Closure Date:
4 Implement a plan to ensure STAR analysts place more emphasis on and assess all procedural deficiency elements included on the quality review checklist.
Closure Date:
5 Establish adequate policies, procedures, and monitoring to ensure corrections are completed timely and accurately.
Closure Date:
6 Ensure STAR develops a plan to provide usable data and meaningful feedback to assist regional offices in improving the quality of decision-making.
Closure Date:
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| 19-07054-174 | Deficiencies in the Quality Review Team Program | Review | ||
1 The OIG recommends that the under secretary for benefits assess the current peer review process and determine whether a more in depth review should be required to ensure claims processing errors are identified.
Closure Date:
2 The OIG recommends that the under secretary for benefits establish a process where a sampling of non error quality reviews undergo peer review to ensure claims processing errors are identified.
Closure Date:
3 The OIG recommends that the under secretary for benefits revise the QRT specialist performance review process to include more objectivity to ensure constructive feedback is provided to promote competency.
Closure Date:
4 The OIG recommends that the under secretary for benefits revise the error reconsideration process to ensure objectivity and adherence to current VBA procedures.
Closure Date:
5 The OIG recommends that the under secretary for benefits improve oversight procedures for monitoring the timeliness of error corrections.
Closure Date:
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| 18-01622-207 | Consult Delays at the Atlanta VA Health Care System in Decatur, Georgia | Hotline Healthcare Inspection | ||
1 The Atlanta VA Health Care System Director reviews the process for non-VA community care consult performance measurements, evaluates compliance with Veterans Health Administration policy, and implements an action plan as needed.
Closure Date:
2 The Atlanta VA Health Care System Director ensures managers review the backlog of open non-VA community care consults and implements an action plan as needed.
Closure Date:
3 The Atlanta VA Health Care System Director verifies that managers develop a process to analyze and confirm non-VA community care staff compliance with daily monitoring according to Veterans Health Administration policy.
Closure Date:
4 The Atlanta VA Health Care System Director evaluates the process for the hiring, training, and supervision of non-VA community care staff, and implements an action plan as needed.
Closure Date:
5 The Atlanta VA Health Care System Director ensures that managers review the patient cases referred to the Atlanta VA Health Care System by the Office of Inspector General, assesses these patients for adverse clinical outcomes, and implements action plans as needed.
Closure Date:
6 The Atlanta VA Health Care System Director makes certain that managers develop a policy to identify non-VA Community Care consults that are administratively closed but do not have relevant medical documentation, and implements an action plan as needed to be in alignment with Veterans Health Administration policy.
Closure Date:
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| 20-00206-180 | Comprehensive Healthcare Inspection of the Marion VA Medical Center in Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures action items are implemented when problems or opportunities for improvement are identified and documented in Executive Leadership Council minutes.
Closure Date:
2 The Chief of Staff 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.
Closure Date:
3 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.
Closure Date:
4 The Chief of Staff evaluates and determines any additional 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 ensures that providers with similar training and privileges complete ongoing professional practice evaluations of licensed independent practitioners.
Closure Date:
6 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures the licensed healthcare professional’s first- or second-line supervisor completes and signs the exit review forms within seven calendar days of the professional’s departure from the medical center.
Closure Date:
7 The Associate Director for Operations evaluates and determines any additional reasons for noncompliance and ensures that medical center managers repair or remove damaged wheelchairs from service.
Closure Date:
8 The Associate Director for Operations evaluates and determines any additional reasons for noncompliance and ensures that staff secure protected health information within laboratory transport containers.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that clinicians complete pain screening 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 ensures that providers complete a behavior 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:
11 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:
12 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 who are initiated on long-term opioid therapy.
Closure Date:
13 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures healthcare providers follow up with patients within the required time frame after 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’ follow-up with patients receiving long-term opioid therapy includes an assessment of adherence to the pain management plan of care.
Closure Date:
15 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers’ follow-up with patients receiving long-term opioid therapy includes effectiveness of intervention(s) provided.
Closure Date:
16 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the medical center’s Pain Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
17 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that Suicide Prevention Safety Plans include all required elements.
Closure Date:
18 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures clinical and non-clinical staff receive annual suicide prevention refresher training.
Closure Date:
19 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that practitioners enter life-sustaining treatment notes that include all required elements in patients’ electronic health records as required.
Closure Date:
20 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that community-based outpatient clinics have a designated Women’s Health Patient Aligned Care Team.
Closure Date:
21 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures processes and procedures are in place for gynecological care coverage 24 hours a day/7 days per week.
Closure Date:
22 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has designated women’s health primary care providers.
Closure Date:
23 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures the availability of timely access to emergency contraceptives at the Evansville VA Clinic.
Closure Date:
24 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required core members are assigned and consistently attend Women Veterans Committee meetings.
Closure Date:
25 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that standard operating procedures align with manufacturers’ guidelines and instructions for use.
Closure Date:
26 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and makes certain that all equipment is entered into the CensiTrac® Instrument Tracking System.
Closure Date:
27 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 an annual risk analysis and reports the analysis to the VISN Sterile Processing Services Management Board.
Closure Date:
28 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that annual airflow testing is conducted in all areas where reusable medical equipment is reprocessed.
Closure Date:
29 The Associate Director for Patient Care Services evaluates and determines any additional reasons for noncompliance and ensures that Sterile Processing Services managers properly complete competency assessments for staff reprocessing reusable medical equipment.
Closure Date:
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| 19-06451-165 | The Veterans Health Administration Did Not Get Secretary’s Approval Before Using Canines for Medical Research | Review | ||
1 The Under Secretary for Health establish a formal process for requesting and obtaining the approval of the VA Secretary for research studies that use canine subjects to comply with applicable restrictions on the use of appropriated funds.
Closure Date:
2 The Under Secretary for Health develop and implement processes for documenting and maintaining records of the VA Secretary’s approval of canine research studies, including the study at the Richmond VAMC that was not included in the Secretary’s August 30, 2019, approval document.
Closure Date:
3 The Under Secretary for Health establish controls for ensuring appropriate funds are not spent for canine research studies before obtaining the VA Secretary’s approval.
Closure Date:
4 The Under Secretary for Health review local accounting records and cost allocations to determine the total amount of FY 2018 and 2019 funds spent on canine research before the VA Secretary approved the studies and report this information to the House and Senate appropriations committees.
Closure Date:
5 The Under Secretary for Health work with the VA Secretary and the chief financial officer to take the steps required by OMB Circular A-11 to determine whether an Antideficiency Act violation occurred and, if so, take appropriate action for the funds obligated and expended for research studies involving canine subjects.
Closure Date:
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| 19-09410-203 | Safety Concerns When Providing Care in the Community at the VA Southern Nevada Healthcare System in North Las Vegas | Hotline Healthcare Inspection | ||
1 The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and makes changes to ensure staff and supervisors are aware of and follow reporting requirements arising from off-facility patient disruptive behavior incidents.
Closure Date:
2 The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and implements changes to address traumatic injury needs of staff who may be experiencing an emotional or mental health injury as a result of a work related incident.
Closure Date:
3 The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies and implements changes to ensure timely notification of threats to targeted staff.
Closure Date:
4 The VA Southern Nevada Healthcare System Director reviews VA Southern Nevada Healthcare System policies for the placement of behavioral flags and makes changes to ensure patient record flags are placed to address immediate safety issues.
Closure Date:
5 The VA Southern Nevada Healthcare System Director ensures that VA Southern Nevada Healthcare System VA police fulfill their obligation to fully participate with the Disruptive Behavior Committee, including the triage of Disruptive Behavior Response System entries, and confirms that potential criminal or safety issues are timely addressed.
Closure Date:
6 The VA Southern Nevada Healthcare System Director reviews the VA Southern Nevada Healthcare System Housing and Urban Development-Veterans Affairs Supporting Housing staffing levels and practices to ensure staffing and training safely meet the demands of the program.
Closure Date:
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14957