Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00055-38 | Comprehensive Healthcare Inspection of the St. Cloud VA Health Care System, Minnesota | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
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2 The chief of staff confirms that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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3 The chief of staff ensures that clinicians provide and document patient/caregiver education and evaluate understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
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4 The facility director ensures that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
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| 19-00051-40 | Comprehensive Healthcare Inspection of the Chalmers P. Wylie Ambulatory Care Center, Columbus, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors managers’ compliance.
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2 The facility director makes certain that the patient safety manager or designee includes all required components in each root cause analysis to ensure quality and consistency of reviews and monitors the patient safety manager’s compliance.
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3 The facility director ensures that the appropriate committee reviews all resuscitative episodes, to include the required components, and monitors committee’s compliance.
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4 The chief of staff ensures that clinical managers define the focused professional practice evaluation process in advance and monitors clinical managers’ compliance.
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5 The chief of staff confirms that clinical managers ensure ongoing professional practice evaluations include service chief’s determination to continue privileges based on the results of the evaluations within the re-privileging period and monitors clinical managers’ compliance.
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6 The chief of staff makes certain that the facility’s Medical Executive Board considers ongoing professional practice evaluation results in its decision to recommend continuation of provider privileges and monitors compliance.
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7 The facility director makes certain that monthly and quarterly controlled substances inspection reports are reviewed at least on a quarterly basis by the facility committee responsible for quality oversight and that identified corrective actions are followed up until completion and monitors compliance.
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8 The chief of staff ensures that mental health and primary care providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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9 The chief of staff makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
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10 The chief of staff ensures clinicians maintain and communicate accurate patient medication information in patients’ electronic health record and reconcile medications and monitors clinicians’ compliance.
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11 The facility director confirms that the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
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12 The chief of staff ensures that ordering providers notify patients of abnormal results within the required time frame and monitors providers’ compliance.
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13 The facility director ensures that the chief of staff makes certain that all anesthesia providers follow required steps to ensure consistent and safe handling, storage, and security of controlled substances and monitors compliance.
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| 19-00048-48 | Comprehensive Healthcare Inspection of the Coatesville VA Medical Center, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that all required representatives consistently participate in the interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
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2 The facility director ensures that managers consistently implement corrective actions identified in root cause analyses and monitors compliance.
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3 The chief of staff ensures that the Medical Executive Board reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the facility director.
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4 The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
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5 The associate director verifies that the inventory of resources and assets that may be needed during an emergency is documented and reviewed annually and monitors compliance.
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6 The associate director ensures that emergency generators are tested in accordance with required standards and results are documented and monitors compliance.
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7 The facility director makes certain that controlled substances inspectors are appointed in writing and monitors compliance.
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8 The facility director makes certain that the controlled substances coordinators complete annual competency assessment of inspectors and monitors coordinators’ compliance.
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9 The facility director makes certain that the controlled substances inspectors verify controlled substance orders for five randomly selected dispensing activities and monitors coordinators’ compliance.
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10 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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11 The chief of staff makes certain that clinicians document patient and/or caregiver understanding of the education provided about the safe and effective use of newly prescribed medications and monitors the clinicians’ compliance.
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12 The chief of staff makes certain the Women Veterans Health Committee is comprised of the required core members and monitors committee’s compliance.
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13 The facility director makes certain that if the urgent care center operates 24 hours a day, seven days a week, that the national director of Emergency Medicine has approved a waiver.
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14 The facility director makes certain that the urgent care center is staffed with at least two registered nurses at all times of operation and monitors the center’s compliance.
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15 The facility director ensures that support services are available to the urgent care center during all hours of operation and monitors compliance.
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16 The facility director makes certain the urgent care center does not receive patients via ambulance and monitors compliance.
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| 17-03718-240 | Inadequate Oversight of the Medical/Surgical Prime Vendor Program’s Order Fulfillment and Performance Reporting for Eastern Area Medical Centers | Audit | ||
1 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to develop a formal process to validate correct order fulfillment reporting by the prime vendors, ensure the correct algorithms are used, and help prevent missed opportunities to identify and mitigate issues.
2 The executive in charge, office of under secretary for health, requires the Healthcare Commodities Program Office to ensure Medical/Surgical Prime Vendor Next Generation contracting officer’s representatives get timely access to the performance metric reporting, such as reporting on correct order fulfillment.
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3 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor contracting officer’s representatives to ensure performance metric reporting is reviewed for accuracy.
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4 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to strengthen processes and procedures so that staff use the Medical/Surgical Prime Vendor Next Generation formulary to change unit of issuance and product pricing information in the item master files.
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5 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to confirm that prime vendor American Medical Depot uses formulary sources when fulfilling requests for medical or surgical products under the Medical/Surgical Prime Vendor Next Generation.
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6 The executive in charge, office of under secretary for health, requires the director, VHA Procurement and Logistics Office, to see that all those who order supplies under the Medical/Surgical Prime Vendor-Next Generation contract have proper delegated authority.
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7 The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to monitor the Integrated Product Team’s development and implementation of a process to validate performance metric reporting such as on unadjusted fill rates.
8 The executive in charge, office of under secretary for health, requires the Procurement and Logistics Office to strengthen controls, monitor the Healthcare Commodities Program Office monthly, and ensure adherence to the established Medical/Surgical Prime Vendor Next Generation program control plan.
9 The executive in charge, office of under secretary for health, and the principal executive director, Office of Acquisition, Logistics, and Construction, require the Healthcare Commodities Program Office and Strategic Acquisition Center to identify and resolve discrepancies between unadjusted fill rate reporting methods used by the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers.
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10 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, direct the Healthcare Commodities Program Office and Strategic Acquisition Center to see that all prime vendors use the unadjusted fill rate calculation methodology in accordance with the Medical/Surgical Prime Vendor Next Generation contract.
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11 The executive in charge, office of under secretary for health, and the principal executive director, office of acquisition, logistics, and construction, instruct the Healthcare Commodities Program Office and Strategic Acquisition Center to require the Medical/Surgical Prime Vendor Next Generation prime vendor for select eastern area VA medical centers to provide corrected unadjusted fill rates for the fiscal year 2018 and current reporting periods.
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| 17-04859-196 | Insufficient Oversight of VA’s Undelivered Orders | Audit | ||
1 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure relevant staff review and reconcile open orders to identify and deobligate excess funds for completed, canceled, or orders recorded more than once, and ensure the relevant staff follow existing policy regarding required reviews of open obligations.
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2 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure that obligation policy includes specific time frames for effective interdepartmental communication to ensure timely identification of funds that are no longer needed for their original purpose and could be deobligated.
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3 The assistant secretary for management and chief financial officer should develop a process for monitoring performance across the Department regarding reconciliation of open orders and develop a plan to share results with appropriate officials for their action.
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4 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with existing policy, which requires that obligations be adjusted when actual costs of goods and services are known to be less than the initially recorded amount.
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5 The Veterans Health Administration chief financial officer and the Veterans Health Administration executive director for procurement should ensure compliance with policy, which requires that obligations be supported by sufficient documentary evidence that substantiates the validity and proper authorization of obligations and that the evidence be retained and readily available upon request.
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6 The Veterans Health Administration executive director for procurement should ensure timely modifications or closing of contracts, when applicable, to allow for the deobligation of funds no longer required.
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| 18-06504-27 | Comprehensive Healthcare Inspection of the Kansas City VA Medical Center, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that clinicians peer review all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
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2 The chief of staff verifies that clinicians complete peer reviews of all completed suicides that occur within seven days after discharge from inpatient mental health treatment or residential care units and monitors clinicians’ compliance.
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3 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
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4 The associate director ensures electronic safety data sheets are readily accessible to employees and monitors compliance.
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5 The associate director confirms that unit managers store clean and dirty medical equipment separately and monitors managers’ compliance.
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6 The associate director ensures the mental health nursing station prevents unauthorized entry and monitors compliance.
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7 The associate director ensures that the hazard vulnerability analysis and the emergency operations plan are approved by executive leadership and monitors compliance.
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8 The facility director ensures that controlled substances inspection program staff complete reconciliation of one random day’s return of stock to the pharmacy from every automated dispensing cabinet during monthly inspections and monitors program staff compliance.
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9 The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
10 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:
11 The chief of staff ensures clinicians reconcile medications and maintain accurate medication information in patients’ electronic health records and monitors clinicians’ compliance.
Closure Date:
12 The chief of staff makes certain that the Women Veterans Health Committee includes all required core members and monitors the committee’s compliance.
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13 The chief of staff ensures the Women Veterans Health Committee reports to executive leaders and monitors the committee’s compliance.
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14 The chief of staff makes certain that the emergency department director maintains a backup call schedule for emergency department providers and monitors the director’s compliance.
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| 19-00024-39 | Comprehensive Healthcare Inspection of the VA Manila Outpatient Clinic, Pasay City, Philippines | Comprehensive Healthcare Inspection Program | ||
1 The chief medical officer ensures that focused and ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
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2 The facility director makes certain that controlled substances inspectors perform a complete count of the pharmacy’s controlled substances physical inventory during monthly inspections and monitors inspectors’ compliance.
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3 The chief medical officer ensures the military sexual trauma coordinator communicates the status of military sexual trauma services and initiatives with facility leaders and monitors coordinator’s compliance.
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4 The chief medical officer makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data.
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5 The chief medical officer ensures providers complete comprehensive diagnostic evaluations within the required time frame for all new patients referred for mental health services for military sexual trauma and monitors providers’ compliance.
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6 The chief medical officer makes certain that clinicians provide and document patient and/or caregiver education about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
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7 The chief medical officer ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
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| 19-06562-30 | Alleged Deficiencies in Oncology Psychosocial Distress Screening and Root Cause Analysis Processes at a Facility in VISN 15 | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Medical 15 Facility Director conducts an evaluation of radiation oncology clinic mental health consultation and treatment program needs and adjusts mental health provider coverage as warranted.
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2 The Veterans Integrated Service Network Medical 15 Facility Director ensures that all components of the oncology service psychosocial distress screening standard operating procedures include screening frequency consistent with National Comprehensive Cancer Network’s ideal standards.
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3 The Veterans Integrated Service Network Medical 15 Facility Director guarantees that the patient safety program maintains effective processes to track action items to completion and monitors compliance.
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4 The Veterans Integrated Service Network Medical 15 Facility Director ensures that staff complete Suicide Behavior and Overdose Reports and Behavioral Health Autopsies, as required by the Veterans Health Administration.
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| 19-00049-43 | Comprehensive Healthcare Inspection of the VA Butler Health Care Center, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that the Medical Executive Committee considers and documents the deliberation of professional practice data prior to granting privileges and monitors committee’s compliance.
Closure Date:
2 The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
3 The chief of staff makes certain that clinicians provide and document patient/caregiver education about the safe and effective use of newly prescribed medications and evaluate understanding when education is provided and monitors clinicians’ compliance.
Closure Date:
4 The chief of staff ensures clinicians review and reconcile medications and monitors the clinicians’ compliance.
Closure Date:
5 The facility director confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
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| 18-02300-236 | Delays and Deficiencies in Management of Selected Radiology and Nuclear Medicine Outpatient Exams | Audit | ||
1 Ensure facility staff evaluate scheduling workload and that medical support assistant staffing is adequately distributed for scheduling radiology exam requests in a timely manner.
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2 Provide formal guidance to facilities for establishing clinic management models for adequate radiology resources, including staffing and equipment.
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3 Ensure facility radiology and nuclear medicine services monitor exam requests pending greater than seven days and address them in a timely manner.
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4 Confirm with each facility director that they reviewed each record and took appropriate action as they deemed necessary for the three completed requests with additional follow-up care needs.
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5 Develop and implement a plan for improved radiology and nuclear medicine oversight at the Veterans Integrated Service Network level.
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6 Implement a mechanism to routinely audit canceled exam requests, ensuring the requests are in accordance with VA radiology and nuclear medicine policies and procedures for canceling exam requests, and taking corrective actions as needed based on audit results.
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7 Create a method to notify radiology and nuclear medicine leaders at all VA medical facilities when guidance is released. The method should be streamlined with maximum distribution and ensure receipt and acknowledgment by affected radiology and nuclear medicine leaders.
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8 Confirm with each facility director that they review each record and take appropriate action for five of the six canceled requests with outstanding exam needs.
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15039