Recommendations
2056
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-01751-39 | Improvements in Patient Safety, but Concerns Identified with Staffing Shortages Affecting Quality of Care at the VA Community Living Center in Miles City, Montana | Hotline Healthcare Inspection | ||
1 The VA Montana Healthcare System Director reviews Community Living Center physician coverage to identify barriers and gaps, determines options for resolution, and completes and executes a coverage plan to ensure residents’ care and staff’s needs are met when the physician is not available for extended periods.
Closure Date:
2 The VA Montana Healthcare System Director reviews Community Living Center physical therapy staffing to identify barriers and gaps, determines options for resolution, and completes and executes a hiring plan to ensure residents’ care and staff’s needs are met.
Closure Date:
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| 24-00194-42 | Leaders Failed to Ensure a Dermatologist Provided Quality Care at the Carl T. Hayden VA Medical Center in Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Carl T. Hayden Medical Center Director ensures that supervisory staff take effective actions to correct clinical deficiencies.
2 The Carl T. Hayden Medical Center Director identifies electronic health records containing the dermatologist’s misuse of copy and paste and takes action as warranted to ensure the safety of patients.
3 The Carl T. Hayden Medical Center Director ensures that service chiefs and patient safety staff report instances of misuse of copy and paste to Health Information Management System staff.
4 The Carl T. Hayden Medical Center Director ensures a comprehensive review is conducted to determine if the dermatologist documented electrodesiccation and curettage procedures that were not performed and takes action as warranted, including providing patients with clinical care and disclosures if needed, and notifying the Office of Inspector General.
5 The Carl T. Hayden Medical Center Director ensures that the Chief of Staff is aware of and addresses pervasive deficiencies, when they exist, in clinical care provided at the facility.
6 The Desert Pacific Healthcare System Network Director evaluates reasons for noncompliance with the state licensing board reporting policy with regard to the dermatologist, and takes action as needed.
7 The Carl T. Hayden Medical Center Director ensures that a dermatologist conducts a review of the dermatologist’s patients with consideration of the concerns laid out in this report, to identify patients who may need follow-up care and disclosures, and takes action as warranted.
8 The Carl T. Hayden Medical Center Director reviews with facility leaders, disclosure requirements outlined in VHA Directive 1004.08, Disclosure of Adverse Events to Patients.
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| 24-00566-16 | Care in the Community Inspection of VA Sierra Pacific Network (VISN 21) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.
Closure Date:
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.
Closure Date:
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
Closure Date:
4 The Veteran Integrated Service Network Director, in conjunction with facility directors, ensures facility staff scan all community care documents into the patient’s electronic health record within five business days of receipt.
Closure Date:
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain medical documentation prior to administratively closing consults.
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative closure of consults that are not low risk.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.
Closure Date:
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.
Closure Date:
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff schedule patients for community care appointments within seven days of consult entry or receipt in the department.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended scheduled community care appointments and received care.
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.
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| 23-01739-26 | Care in the Community Inspection of VA Desert Pacific Healthcare Network (VISN 22) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per calendar year.
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff complete the operating model staffing tool reassessment every 90 days.
Closure Date:
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.
Closure Date:
4 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures VHA staff scan all community care documents into the patient’s electronic health record within five business days of receipt.
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff attach diagnostic imaging results to the Community Care Consult Result note.
Closure Date:
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative consult closure.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate requests for additional services and supporting medical documentation in patients’ electronic health records.
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff verify community care providers’ signatures on requests for additional services forms.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send letters to community providers when they deny requests for additional services.
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| 24-00587-45 | Healthcare Facility Inspection of the VA Southern Oregon Healthcare System in White City | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders relocate papers and folders outside of patient examination rooms or secure them in protective coverings to mitigate the risk of infection.
Closure Date:
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| 23-03485-03 | VBA Provided Accurate Training on Processing PACT Act Claims but Did Not Fully Evaluate Its Effectiveness | Review | ||
1 Complete level 1 summary reports for the Pension and Fiduciary Service fiscal year 2023 PACT Act training courses and provide feedback from the reports to training staff.
Closure Date:
2 Establish a plan to conduct all four levels of evaluation for PACT Act training and provide feedback to training staff.
Closure Date:
3 Establish deadlines in training evaluation plans for the creation of summary reports.
Closure Date:
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| 24-00608-46 | Healthcare Facility Inspection of the VA Poplar Bluff Health Care System in Missouri | Healthcare Facility Inspection | ||
1 The OIG recommends the Veterans Integrated Service Network Director takes actions to ensure stable and consistent leadership at the facility.
Closure Date:
2 The OIG also recommends Veterans Integrated Service Network leaders assist facility leaders to improve interactions with local union leaders.
Closure Date:
3 The OIG recommends the Interim Medical Center Director ensures all security cameras are operational.
Closure Date:
4 The OIG recommends the Interim Medical Center Director ensures primary care teams are staffed according to Veterans Health Administration guidelines.
Closure Date:
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| 24-00550-32 | Healthcare Facility Inspection of the VA Chillicothe Healthcare System in Ohio | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders ensure staff understand procedures for cleaning equipment and continue to monitor the physical separation of clean and dirty items in storage spaces.
2 The OIG recommends that primary care leaders incorporate feedback from primary care staff and include them in process improvement projects.
Closure Date:
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| 24-00390-41 | Inspection of Pacific District 5 Vet Center Operations | Vet Center Inspection Program | ||
1 The District Director, in conjunction with the Deputy District Director, develops a contingency coverage plan to ensure oversight during periods of vet center director vacancies.
Closure Date:
2 The District Director monitors district leaders’ compliance with completion of morbidity and mortality reviews for client deaths by suicide, including timeliness, as required.
Closure Date:
3 The District Director ensures district leaders are aware of the Readjustment Counseling Service policy requirements to provide oversight of morbidity and mortality review completion, including panel member assignments, participation of affected vet center staff, report completion, reporting of completion delays, and information dissemination.
4 The District Director determines reasons vet center counselors did not complete safety plan components for clients assessed at intermediate or high suicide risk level in either acute, chronic, or both categories; ensures completion of safety plans for all active clients assessed at intermediate or high suicide risk levels; and monitors compliance across all zone vet centers.
5 The District Director determines reasons staff did not document providing safety plans to clients, ensures all active clients assessed at intermediate or high suicide risk levels receives a safety plan, and monitors compliance across all zone vet centers.
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| 24-01623-30 | Improvement in the Patient Safety Program with Continued Opportunities to Strengthen Veterans Integrated Service Network 7 Oversight at the Tuscaloosa VA Medical Center in Alabama | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director confirms that the patient safety officer reviews investigations by subject matter experts for Joint Patient Safety Reporting events.
2 The Veterans Integrated Service Network Director provides evidence to demonstrate the Patient Safety Office is completing reviews of a sample of patient safety events that includes analysis of content, recommendations, and required actions, as outlined in Veterans Health Administration Directive 1050.01.
3 The Veterans Integrated Service Network Director ensures that the Veterans Integrated Service Network 7 Quality and Patient Safety Committee minutes reflect that the patient safety officer conducted analysis of patient safety data to identify opportunities for improvement and provided guidance on facilities’ action plans to address the deficiencies.
Closure Date:
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14921