Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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:
| ||||
| 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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| 19-09416-186 | Comprehensive Healthcare Inspection of the John J. Pershing VA Medical Center in Poplar Bluff, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Interim 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:
2 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures clinical managers define and document expectations for focused professional practice evaluations in provider profiles prior to assessment.
Closure Date:
3 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 a provider’s departure from the medical center.
Closure Date:
4 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 factors, and aberrant drug-related behaviors on all patients prior to initiating long-term opioid therapy.
Closure Date:
5 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers document justification for concurrent opioid and benzodiazepine medication therapy.
Closure Date:
6 The Chief of Staff determines the reason for noncompliance and make certain that healthcare providers consistently conduct urine drug testing as required for patients on long-term opioid therapy.
Closure Date:
7 The Chief of Staff determines the reasons for noncompliance and makes certain that healthcare providers obtain and document informed consent consistently for patients prior to initiating long-term opioid therapy.
Closure Date:
8 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures providers follow up with patients within the required time frame after initiating long-term opioid therapy.
Closure Date:
9 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that providers’ follow-up of patients receiving long-term opioid therapy includes an assessment of pain management care plan adherence and intervention effectiveness.
Closure Date:
10 The Interim Medical Center Director determines the reasons for noncompliance and ensures that the Pain Management Sub-Committee monitors the quality of pain assessment and the effectiveness of pain management interventions.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that clinicians conduct four follow-up appointments, either face-to-face or telephonic with documented consent, within the required time frame.
Closure Date:
12 The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain staff receive annual suicide prevention refresher training.
Closure Date:
13 The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers or arrangements for leave coverage when CBOCs have only one designated provider.
Closure Date:
14 The Interim Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Women Veterans Health Committee is comprised of the required core members.
Closure Date:
15 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:
16 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:
17 The Associate Director for Patient Care Services determines the reasons for noncompliance and ensures that Sterile Processing Services staff properly complete competency assessments for reprocessing reusable medical equipment.
Closure Date:
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| 19-06864-183 | Comprehensive Healthcare Inspection of the Harry S. Truman Memorial Veteran’s Hospital in Columbia, Missouri | Comprehensive Healthcare Inspection Program | ||
1 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:
2 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:
3 The Medical Center Director determines reasons for noncompliance and ensures that root cause analyses include all required review elements.
Closure Date:
4 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:
5 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that service chiefs complete provider exit review forms within seven calendar days of licensed health care professionals’ departure from the medical center.
Closure Date:
6 The Chief of Staff evaluates and determines any additional reasons for noncompliance and ensures that providers complete a behavior risk assessment on all 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 healthcare providers consistently conduct urine drug testing as required for patients on 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 obtain and document informed consent for patients when initiating long-term opioid therapy.
Closure Date:
9 The Chief of Staff determines reasons for noncompliance and ensures healthcare providers follow up with patients within the required timeframe after initiating long-term opioid therapy.
Closure Date:
10 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that staff receive annual suicide prevention refresher training.
Closure Date:
11 The Chief of Staff evaluates and determines any additional reasons for noncompliance and makes certain that practitioners complete and document all required elements of life-sustaining treatment plan progress notes.
Closure Date:
12 The Medical Center Director evaluates and determines any additional reasons for noncompliance and certifies that a multidisciplinary committee is established to review proposed life-sustaining treatment plans.
Closure Date:
13 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that the Advisory Committee For Women Veterans includes required core members.
Closure Date:
14 The Associate Director for Patient Service evaluates and determines any additional reasons for noncompliance and makes certain that Chief of Sterile Processing Services completes valid competency assessments for staff reprocessing reusable medical equipment.
Closure Date:
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| 19-00230-190 | Waste and Abuse by the Former Assistant Secretary for Human Resources and Administration | Administrative Investigation | ||
1 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction requires in any award made on a noncompetitive basis that the contracting officer obtain a written disclosure and certification by the program sponsor, contracting officer’s representative, and other staff involved in the procurement as appropriate, disclosing any personal or professional relationship between such staff and vendor personnel.
Closure Date:
2 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the conduct and performance of the contracting officer, the Agency Competition Advocate, and the two higher-level supervisors involved in this procurement.
Closure Date:
3 The Assistant Secretary for Human Resources and Administration/Operations, Security, and Preparedness determines what administrative action should be taken, if any, with respect to the conduct and performance of the HR&A Program Director and the Contracting Officer’s Representative.
Closure Date:
4 VA’s Senior Procurement Executive determines what action, if any, should be taken with respect to the contracting officer’s warrant consistent with the authority granted by VA Acquisition Regulation § 801.690-6.
Closure Date:
5 The Acting General Counsel reviews the circumstances of this procurement and uses that information to help determine whether it is appropriate for counsel to sign attestations on Justification and Approval forms, and issues policy guidance in accordance with that determination.
Closure Date:
6 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction, in consultation with the Office of General Counsel, reviews the Small Business contract to determine what actions should be taken, if any, to recover funds or otherwise address the waste of VA funds.
Closure Date:
7 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics and Construction determines what administrative action, if any, should be taken with respect to the contracting officers’ acceptance of substitute performance that provided no value to VA.
Closure Date:
8 The Assistant Secretary of Human Resources and Administration (HR&A) / Operations, Security, and Preparedness determines what administrative action to take, if any, with respect to the Contracting Officer Representative’s failure to perform diligence sufficient to identify the cloud-computing issues associated with this procurement.
Closure Date:
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| 20-00082-189 | Comprehensive Healthcare Inspection of the Tomah VA Medical Center in Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff determines the reasons for noncompliance and ensures all staff complete annual suicide prevention refresher training.
Closure Date:
2 The Medical Center Director evaluates and determines any additional reasons for noncompliance and ensures that each community-based outpatient clinic has at least two designated women’s health primary care providers.
Closure Date:
3 The Medical Center Director evaluates and determines any additional reasons for noncompliance and makes certain that required members are included in the Women Veterans Health Committee charter and attend the quarterly meetings.
Closure Date:
4 The Associate Director for Patient Care Services 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.
Closure Date:
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| 19-00017-191 | Review of Highly Rural Community-Based Outpatient Clinics' Limited Access to Select Specialty Care | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health completes a specialty care needs assessment for highly rural community-based outpatient clinics to include internet bandwidth and telehealth equipment and develops options for the delivery of safe patient care.
Closure Date:
2 The Under Secretary for Health ensures that the Veterans Health Administration Site Tracking system validation process is completed by each Veterans Integrated Service Network as required and monitors for compliance.
Closure Date:
3 The Under Secretary for Health ensures that facilities and Veterans Integrated Service Networks maintain accurate and current information on websites as required and monitors for compliance.
Closure Date:
4 The Under Secretary for Health completes an assessment to determine whether highly rural community-based outpatient clinics that are located in a non-VA community hospital or health care center are fully utilizing the resources available at the non-VA facilities and takes action as indicated.
Closure Date:
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| 19-09377-192 | Anesthesia Provider Practice Concerns at the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates review of the Veterans Health Administration’s credentialing policy to determine the need for requirement clarification related to prior employment history to include applicant listing of locum tenens contracting companies.
Closure Date:
2 The W. G. (Bill) Hefner VA Medical Center Director ensures credentialing and privileging staff verify applicants’ information within the required timeframe outlined by Veterans Health Administration policy and monitors for compliance.
Closure Date:
3 The W. G. (Bill) Hefner VA Medical Center Director ensures annual proficiency reports are completed and maintained consistent with Veterans Health Administration requirements and monitors for compliance.
Closure Date:
4 The W. G. (Bill) Hefner VA Medical Center Director ensures all available performance and competency information is provided to the Professional Standards Board for consideration during provider probationary and reprivileging reviews and monitors for compliance.
Closure Date:
5 The W. G. (Bill) Hefner VA Medical Center Director ensures that all staff are trained on reporting patient safety events using the correct reporting system and monitors for compliance.
Closure Date:
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15039