Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-05113-81 | Review of Veterans Health Administration Community Living Centers and Corresponding Star Ratings | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health supplements the use of Community Living Center Compare with adjustment measures to better address the Community Living Center to Centers for Medicare and Medicaid Services comparison challenges for veterans, their families, and the public.
Closure Date:
2 The Under Secretary for Health continues to develop specific measures that employ a more rigorous risk adjustment to better measure staffing and quality performance with respect to the Community Living Center population.
Closure Date:
3 The Under Secretary for Health develops a resource that works in conjunction with other information about Community Living Centers to provide an understandable narrative for veterans, their families, and the public.
Closure Date:
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| 18-05738-56 | Veterans Received Inaccurate Disability Benefit Payments After Reserve or National Guard Drill Pay Adjustments | Review | ||
1 The OIG recommended the under secretary for benefits conduct a review of automatically and manually completed fiscal year 2016 drill pay adjustments that involved active duty military periods during that fiscal year, and take corrective actions as necessary.
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2 The OIG recommended the under secretary for benefits conduct a review of automatically and manually completed fiscal year 2016 drill pay adjustments that involved a response to the proposal letter, and take corrective actions as necessary.
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3 The OIG recommended the under secretary for benefits remind Intake Processing Center staff of their responsibilities for processing responses to drill pay proposal letters, including the appropriate actions to take when a response is received disagreeing with the proposal, and implement a plan to ensure staff compliance.
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4 The OIG recommended the under secretary for benefits implement a plan to provide detailed training for VBA staff who process drill pay adjustments and monitor the effectiveness of the training.
Closure Date:
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| 19-06435-84 | Concern Regarding a Patient Death and Alleged Conflicts of Interest at the VA Western Colorado Health Care System, Grand Junction | Hotline Healthcare Inspection | ||
1 The VA Western Colorado Health Care System Director ensures the VA Western Colorado Health Care System Chief of Staff evaluate the management of the identified patient’s abnormal test results and provide re education to all primary care providers on their duties when alerted to abnormal blood smear results.
Closure Date:
2 The VA Western Colorado Health Care System Director requests a conflict of interest review from the VA Office of General Counsel regarding the urologists’ ownership of the extracorporeal shock wave lithotripsy company and provides an accurate description of the alternate forms of treatment and the comparable costs associated with those treatments.
Closure Date:
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| 19-06757-70 | Little Rock VARO Employee Inaccurately Established and Decided Claims | Review | ||
1 Review rating decisions made by the rating veterans service representative since being released on single-signature status, and correct any decisions found to be made in error.
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2 Ensure rating decisions involving clear and unmistakable errors are signed by a quality review specialist and the veterans service center manager, or their designee.
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3 Ensure rating veterans service representatives do not have the function to establish claims in VA’s electronic system.
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| 19-06866-68 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 1: VA New England Healthcare System, Bedford, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The network director ensures that staff at each Veterans Integrated Service Network facility perform the required acute inpatient stay reviews and monitors staff compliance.
Closure Date:
2 The quality management officer confirms that an interdisciplinary group at each facility reviews utilization management data and monitors the group’s compliance.
Closure Date:
3 The quality management officer makes certain that staff at each facility annually complete a minimum of eight root cause analyses and monitors staff compliance.
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4 The chief medical officer ensures that facility clinical managers define criteria in advance for licensed independent practitioners’ focused professional practice evaluations and monitors clinical managers’ compliance.
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5 The chief medical officer confirms that facility clinical managers include service-specific criteria in ongoing professional practice evaluations for licensed independent practitioners and monitors clinical managers’ compliance.
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6 The chief medical officer confirms that ongoing professional practice evaluation results are based on evaluation by another provider with similar training and privileges and monitors compliance.
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7 The chief medical officer verifies that facilities’ executive committee of the medical staff document the decision to recommend continuing privileges for licensed independent practitioners based on ongoing professional practice evaluation results and monitors committees’ compliance.
Closure Date:
8 The chief medical officer makes certain that facility clinical managers clearly define and share in advance the expectations, outcomes, and time frames with licensed independent practitioners for focused professional practice evaluations for cause and monitors clinical managers’ compliance.
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9 The deputy network director ensures a written policy establishes and maintains a Veterans Integrated Service Network-level comprehensive environment of care program.
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10 The deputy network director makes certain that the emergency management committee conducts an annual review of the emergency operations plan, continuity of operations plan, and hazards vulnerability analysis and monitors the committee’s compliance.
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11 The deputy network director makes certain that the emergency management committee conducts, documents, and sends an annual review of the collective Veterans Integrated Service Network-wide strengths, weaknesses, priorities, and requirements for improvement to leadership for review and approval and monitors the committee’s compliance.
Closure Date:
12 The quality management officer reviews Veterans Integrated Service Network facilities’ controlled substances inspection quarterly trend reports.
Closure Date:
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| 19-00054-72 | Comprehensive Healthcare Inspection of the Alaska VA Healthcare System, Anchorage, Alaska | Comprehensive Healthcare Inspection Program | ||
1 The facility director ensures that the patient safety manager completes a minimum of eight root cause analyses each fiscal year and monitors the patient safety manager’s compliance.
Closure Date:
2 The facility director ensures that a formal process is established to review override reports and monitors compliance.
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3 The facility director makes certain that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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4 The chief of staff verifies that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
5 The chief of staff ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
Closure Date:
6 The facility director confirms that the Women’s Health Committee is comprised of the required core members and monitors committee’s compliance.
Closure Date:
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| 19-06378-73 | Deficiencies in the Women Veterans Health Program and Other Quality Management Concerns at the North Texas VA Healthcare System | Hotline Healthcare Inspection | ||
1 The VA North Texas Health Care System Director takes steps to ensure sufficient staffing to provide gender-specific care by designated women’s health primary care providers.
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2 The VA North Texas Health Care System Director ensures steps are taken to reduce panel sizes of designated women’s health primary care providers as required by Veterans Health Administration policy.
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3 The VA North Texas Health Care System Director reviews the Veterans Health Administration policy recommended extended appointment times for comprehensive women veterans healthcare examinations and takes action as appropriate to achieve compliance.
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4 The VA North Texas Health Care System Director takes steps to ensure that appropriate resources, such as equipment, supplies, and space, are adequate to support comprehensive women veterans healthcare.
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5 The VA North Texas Health Care System Director takes steps to ensure that the Women Veterans Program Manager participates in the environment of care rounds and monitors for compliance with Veterans Health Administration policy.
Closure Date:
6 The VA North Texas Health Care System Director evaluates clinic areas where gender specific primary care is currently provided and when planning renovations to existing areas to ensure adequate restroom access for women veterans and takes action as appropriate.
Closure Date:
7 The VA North Texas Health Care System Director continues to evaluate and support staffing changes in the gynecology specialty clinic to enhance services.
Closure Date:
8 The VA North Texas Health Care System Director ensures implementation of an effective tracking mechanism to ensure VA providers receive results for women veterans referred to care in the community and monitors for compliance with Veterans Health Administration policy.
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9 The VA North Texas Health Care System Director verifies review of the electronic health records of women veterans referred to Care in the Community whose medical records have not been obtained and takes action if indicated.
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10 The VA North Texas Health Care System Director takes steps to ensure performance and evaluation processes provide the intended assessment of compliance with Veterans Health Administration requirements and monitors for compliance.
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11 The VA North Texas Health Care System Director verifies that institutional disclosures are conducted for events that meet disclosure criteria and monitors for compliance with Veterans Health Administration policy.
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12 The VA North Texas Health Care System Director takes steps to ensure the required number of combined totals of root cause analyses and aggregated reviews are completed, and monitors for compliance with Veterans Health Administration policy.
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13 The VA North Texas Health Care System Director ensures completion of root cause analyses within the required timeframes and monitors for compliance with Veterans Health Administration policy.
Closure Date:
14 The VA North Texas Health Care System Director verifies that staff complete training on policy related to high-risk patient goals of care conversations for life-sustaining treatment plans and monitors for completion of training.
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15 The VA North Texas Health Care System Director ensures staff conduct high-risk patient goals of care conversations for life-sustaining treatment plans as required and monitors for compliance with Veterans Health Administration policy.
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16 The VA North Texas Health Care System Director takes steps to ensure provider documentation of high-risk patient goals of care and life-sustaining treatment plan in the required electronic health record template and monitors for compliance with Veterans Health Administration policy.
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17 The VA North Texas Health Care System Director verifies capture and reporting of all codes to the resuscitation subcommittee and monitors for compliance with Veterans Health Administration policy.
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18 The VA North Texas Health Care System Director ensures that the Critical Care Committee minutes reflect corrective action plans and follow-through to remediate concerns identified by the resuscitation subcommittee and monitors for compliance.
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| 19-07070-75 | A Delay in Patient Notification of Test Results and Other Communication Issues at the Bath VA Medical Center, New York | Hotline Healthcare Inspection | ||
1 The Bath VA Medical Center Director ensures that surrogate providers comply with the facility’s notification policy when providing coverage.
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2 The Bath VA Medical Center Director ensures that the Bath VA Medical Center Patient Transfer Policy clearly defines a process for outpatient transfers to a higher level of care utilizing facility paramedics.
Closure Date:
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| 18-05121-36 | Improvements Are Needed in the Community Care Consult Process at VISN 8 Facilities | Audit | ||
1 Develop and implement a mechanism for VA facilities and their respective VA community care departments to routinely identify and exchange wait time data to help make decisions that reduce patient wait times.
Closure Date:
2 Routinely monitor the timeliness of each distinct stage of the community care consult process so Veterans Integrated Service Network 8 facilities can identify specific delays.
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3 Ensure facilities routinely monitor the Office of Community Care staffing tool and take appropriate actions to confirm actual staffing levels are sufficient to meet workloads in a timely manner.
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4 Ensure community care administrative staff are effectively cross-trained to carry out applicable administrative consult processing duties to streamline scheduling and authorizations, and implement a control to monitor whether facilities are processing community care consults in accordance with Office of Community Care guidance and recommendations.
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5 Develop and implement specific facility plans to address the backlog of open consults and the growing number of new consults.
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| 19-00046-60 | Comprehensive Healthcare Inspection of the Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that required representatives participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
Closure Date:
2 The chief of staff ensures that the Cardiopulmonary Resuscitation Committee reviews each resuscitative episode under the facility’s responsibility and the reviews include required elements and monitors committee’s compliance.
Closure Date:
3 The chief of staff confirms clinical staff responding to resuscitation events have basic or advanced cardiac life support certification and monitors clinical staff compliance.
Closure Date:
4 The chief of staff ensures service chiefs include defined time frames in focused professional practice evaluations and monitors service chiefs’ compliance.
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5 The chief of staff confirms that service chiefs ensure that focused professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
Closure Date:
6 The chief of staff makes certain service chiefs include service-specific criteria for ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
7 The chief of staff confirms that service chiefs ensure that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors service chiefs’ compliance.
Closure Date:
8 The chief of staff makes certain that service chiefs clearly define and share in advance with providers the time frame, expectations, and outcomes for focused professional practice evaluations for cause that do not limit providers’ ability to practice independently for more than 30 days and monitors service chiefs’ compliance.
Closure Date:
9 The associate director for Patient Care Services ensures that nursing staff label multi-dose medication vials with an expiration date upon opening and monitors staff compliance.
Closure Date:
10 The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
11 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
12 The chief of staff ensures clinicians review and reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
Closure Date:
13 The facility director ensures that the facility has a full-time women veterans program manager.
Closure Date:
14 The chief of staff confirms that the Women Veterans Health Committee includes required core members and reports to a clinical executive level committee and monitors the committee’s compliance.
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15 The chief of staff ensures that program managers implement a process to track and monitor cervical cancer screenings and follow-up care and monitors program managers’ compliance.
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16 The chief of staff makes certain that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
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17 The chief of staff ensures the chief of Social Work maintains a backup call schedule for emergency department social workers.
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14957