Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
9 The Washington DC VA Medical Center Director ensures that facility staff complete Suicide Behavior and Overdose reports as required.
Closure Date:
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.
Closure Date:
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| 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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15039