Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-07090-90 | Alleged Issues in the Cardiology Department at the Richard L. Roudebush VA Medical Center, Indianapolis, Indiana | Hotline Healthcare Inspection | ||
1 The Richard L. Roudebush VA Medical Center Director reviews and develops cardiology recruitment and retention processes to reach the approved staffing level.
Closure Date:
2 The Richard L. Roudebush VA Medical Center Director explores the possible reasons for difficulties recruiting and retaining cardiologists and takes action to resolve identified issues.
Closure Date:
3 The Richard L. Roudebush VA Medical Center Director ensures that facility staff understand the Veterans Health Administration policy regarding authorized and unauthorized patient wait lists, and monitors compliance.
Closure Date:
4 The Richard L. Roudebush VA Medical Center Director ensures facility managers train staff regarding the consult process and wait list policies, and monitors compliance.
Closure Date:
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| 18-01275-89 | Quality of Care Issues in the Community Living Center and Emergency Department at the Dayton VA Medical Center, Ohio | Hotline Healthcare Inspection | ||
1 The Dayton VA Medical Center Director identifies facility resources and other means for provider education and training to strengthen skills when deficiencies in care are identified during peer reviews.
Closure Date:
2 The Dayton VA Medical Center Director ensures that Peer Review Committee meeting minutes document reasons for changes to peer review levels, and that changes are consistent with its review of relevant aspects of clinical care.
Closure Date:
3 The Dayton VA Medical Center Director ensures review of procedures to make certain gastroenterology staff coordinate care with referring providers and provide staff training on care coordination procedures as needed.
Closure Date:
4 The Dayton VA Medical Center Director makes certain that Community Living Center staff utilize the Situation, Background, Assessment, and Recommendation communication tool and document transfers to the Emergency Department in accordance with Dayton VA Medical Center policy.
Closure Date:
5 The Dayton VA Medical Center Director considers consolidating Medical Center policies related to patient transfers and transports to and from the Emergency Department into one policy to provide clear guidance to staff to effect timely transfers.
Closure Date:
6 The Dayton VA Medical Center Director ensures consistent implementation of standing orders in the Emergency Department.
Closure Date:
7 The Dayton VA Medical Center Director verifies policies and procedures are in place for monitoring of critically ill patients to track deterioration and need for intervention in the Emergency Department and during transport, and monitor compliance.
Closure Date:
8 The Dayton VA Medical Center Director ensures that handoff communication between Emergency Department providers is accurate and documented in the electronic health record during transitions in care in accordance with Dayton VA Medical Center policy, and compliance is monitored.
Closure Date:
9 The Dayton VA Medical Center Director ensures review of results from the revision of the Dayton VA Medical Center policy on threshold for peer review findings to trigger management reviews in order to confirm the revised policy is appropriately sensitive to identify provider practice issues that constitute patient safety concerns, and revise the policy if needed.
Closure Date:
10 The Dayton VA Medical Center Director confirms all code carts in the Emergency Department are processed and secured consistent with Dayton VA Medical Center policy.
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11 The Dayton VA Medical Center Director ensures Emergency Department supplies are secured and maintained consistent with Dayton VA Medical Center policy.
Closure Date:
12 The Dayton VA Medical Center Director ensures continued monitoring and compliance with bar code medication administration policy in the Community Living Center.
Closure Date:
13 The Dayton VA Medical Center Director reviews document management procedures for professional practice evaluations and takes actions as needed to comply with the VA Records Control Schedule.
Closure Date:
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| 18-03251-88 | Alleged Improper Locality Pay for Teleworking Employee | Administrative Investigation | ||
1 The Office of General Counsel communicates to its telework-approving supervisors that they lack authority to grant permanent exceptions to the twice-per-pay-period reporting requirement of 5 C.F.R. § 531.605(d)(1), and that in any instance in which an exception is granted pursuant to 5 C.F.R. § 531.605(d)(2) or any other applicable provision, the supervisor is obligated to periodically reassess the employee’s telework arrangement to determine whether a permanent change of official worksite is necessary.
Closure Date:
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| 19-07119-80 | Telehealth Public-Use Questionnaires Were Used Improperly to Determine Disability Benefits | Review | ||
1 Determine whether public-use disability benefits questionnaires continue to be an effective means of gathering evidence to support claims for benefit entitlement and, if necessary, take steps to discontinue their use.
Closure Date:
2 Update the Veterans Benefits Administration’s adjudication procedures manual to assist claims processors in determining whether public-use disability benefits questionnaires were conducted through telehealth and include specific steps on what to do if claims processors suspect that public-use disability benefits questionnaires were completed via telehealth.
Closure Date:
3 Revise public-use disability benefits questionnaire forms to include a mechanism for the private provider to indicate whether the examination was completed in person or through telehealth.
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4 Notify veterans and private providers on public-facing forums and public-use disability benefits questionnaires that telehealth examinations are not acceptable for use in making benefit entitlement determinations.
Closure Date:
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| 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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
3 Ensure rating veterans service representatives do not have the function to establish claims in VA’s electronic system.
Closure Date:
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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.
Closure Date:
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.
Closure Date:
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.
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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.
Closure Date:
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.
Closure Date:
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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15039