Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-04671-25 | Comprehensive Healthcare Inspection of the VA Greater Los Angeles Healthcare System, California | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that clinicians complete peer reviews for all applicable deaths within 24 hours of admission and monitors clinicians’ compliance.
Closure Date:
2 The associate director for Patient Care Services ensures utilization management reviewers complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors reviewers’ compliance.
Closure Date:
3 The associate director for Patient Care Services ensures that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors compliance.
Closure Date:
4 The associate director for Patient Care Services makes certain that staff label multidose medication vials with an expiration date upon opening and monitors staff compliance.
Closure Date:
5 The associate director for Operations ensures that managers maintain a safe environment in patient care areas and monitors managers’ compliance.
Closure Date:
6 The associate director for Operations ensures that San Luis Obispo VA Clinic staff secure laboratory transport bags containing personally identifiable information and monitors staff compliance.
Closure Date:
7 The associate director for Operations ensures the VA police document response times for panic alarm testing at the locked inpatient mental health unit and monitors compliance.
Closure Date:
8 The associate director for Operations makes certain that bathroom faucets in the inpatient mental health unit are in compliance with the Mental Health Environment of Care Checklist and monitors compliance.
Closure Date:
9 The facility director ensures that the controlled substances coordinator’s monthly summary report includes all discrepancies and findings identified during inspections and monitors coordinator’s compliance.
Closure Date:
10 The facility director makes certain that a quality management committee consistently reviews monthly and quarterly controlled substances program trend reports, including discrepancies identified during inspections, and monitors committee’s compliance.
Closure Date:
11 The facility director makes certain that controlled substances inspectors are appointed in writing to a term not to exceed three years and monitors compliance.
Closure Date:
12 The facility director ensures that the controlled substances coordinator performs and documents competency assessments of the controlled substances inspectors annually and monitors controlled substances coordinator’s compliance.
Closure Date:
13 The facility director confirms that controlled substances inspectors complete monthly inspections and physical inventory counts and monitors inspectors’ compliance.
Closure Date:
14 The facility director ensures that controlled substances program staff reconcile one day’s dispensing from the pharmacy to each dispensing area and one day’s return of stock to the pharmacy and monitors program staff’s compliance.
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15 The facility director ensures that controlled substances inspectors verify controlled substances orders for five random dispensing activities during monthly inspections and monitors inspectors’ compliance.
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16 The facility director makes certain that the controlled substances coordinator refrains from conducting routine inspections and monitors coordinator’s compliance.
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17 The facility director confirms that controlled substances inspectors complete monthly pharmacy inspections and monitors inspectors’ compliance.
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18 The facility director ensures that controlled substances inspectors verify that drugs held for destruction are secured and documented during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
19 The facility director makes certain that controlled substances inspectors verify the inventory count of prescription pads the day of the pharmacy inspection and monitors inspectors’ compliance.
Closure Date:
20 The facility director ensures that controlled substances inspectors verify hard copy controlled substances prescriptions during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
21 The facility director guarantees that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
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22 The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
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23 The chief of staff certifies that clinicians provide and document patient and/or caregiver education about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
24 The chief of staff makes certain clinicians review and reconcile medications and monitors clinicians’ compliance.
Closure Date:
25 The chief of staff ensures that the Women Veterans Health Committee includes required core members, meets at least quarterly, and reports to facility leaders and monitors committee’s compliance.
Closure Date:
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| 19-05916-24 | Alleged Wrongful Death and Deficiencies in Documentation of a Patient’s DNAR Status at the Baltimore VA Medical Center, Maryland | Hotline Healthcare Inspection | ||
1 The VA Maryland Health Care System Director reviews the subject patient’s final episode of care and treatment course and determines if administrative actions are appropriate.
Closure Date:
2 The VA Maryland Health Care System Director establishes a process to monitor the identification, documentation, and communication of patients’ Do Not Attempt Resuscitation status.
Closure Date:
3 The VA Maryland Health Care System Director reviews the process for tracking, documenting, and completing action items in the Executive Committee of the Medical Staff.
Closure Date:
4 The VA Maryland Health Care System Director strengthens the process for tracking code blue/rapid response events to include timely completion of the required documentation and accountability for delinquent documentation.
Closure Date:
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| 19-00033-11 | Comprehensive Healthcare Inspection of the El Paso VA Health Care System, Texas | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that mental health service chiefs clearly define and communicate expectations for focused professional practice evaluations in advance with providers and monitors service chiefs’ compliance.
Closure Date:
2 The chief of staff ensures that service chiefs include service-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
3 The facility director ensures the emergency management coordinator conducts an annual inventory of resources and assets and monitors coordinator’s compliance.
Closure Date:
4 The facility director ensures that an emergency operations plan that describes the response procedures to follow when emergencies occur is developed and maintained as required.
Closure Date:
5 The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
6 The chief of staff ensures that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
7 The chief of staff makes certain that the Women Veterans Health Committee reports to leaders with signed minutes and monitors committee’s compliance.
Closure Date:
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| 18-04667-13 | Comprehensive Healthcare Inspection of the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures clinical managers initiate focused professional practice evaluations that clearly define criteria and communicate time frames in advance and monitors clinical managers’ compliance.
Closure Date:
2 The facility director ensures that pharmacy staff who review monthly balance adjustments do not have electronic access to perform controlled substances balance adjustments and monitors staff compliance.
Closure Date:
3 The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
4 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 evaluate understanding when education is provided and monitors clinicians’ compliance.
Closure Date:
5 The facility director confirms that the Women Veterans Health Committee maintains an active charter, meets quarterly at a minimum, and reports to leadership with signed minutes and monitors committee’s compliance.
Closure Date:
6 The chief of staff ensures providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.
Closure Date:
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| 19-00040-10 | Comprehensive Healthcare Inspection of the Manchester VA Medical Center, New Hampshire | Comprehensive Healthcare Inspection Program | ||
1 The facility director confirms that the patient safety manager includes consideration of relevant literature in root cause analyses and monitors patient safety manager’s compliance.
Closure Date:
2 The chief of staff ensures that clinical managers document in practitioners’ profiles the focused professional practice evaluation criteria defined in advance and monitors clinical managers’ compliance.
Closure Date:
3 The chief of staff ensures that professional practice evaluations include service-specific criteria and monitors compliance.
Closure Date:
4 The chief of staff confirms that specialty providers’ ongoing professional practice evaluations include the minimum required specialty criteria and monitors compliance.
Closure Date:
5 The chief of staff makes certain that the facility’s Medical Executive Council reviews the professional practice data in the consideration to continue provider privileges and monitors compliance.
Closure Date:
6 The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
Closure Date:
7 The associate director ensures that a clean and safe environment is maintained throughout the facility and monitors compliance.
Closure Date:
8 The facility director ensures that military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
Closure Date:
9 The chief of staff ensures providers offer referrals for military sexual trauma-related services for patients with a positive screen and monitors providers’ compliance.
Closure Date:
10 The facility director confirms that primary care and mental health providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
Closure Date:
11 The chief of staff ensures providers document indication for use for newly prescribed medications in patients’ electronic health records and monitors providers’ compliance.
Closure Date:
12 The chief of staff ensures that clinicians provide and document patient/caregiver education and understanding of education provided about the safe and effective use of newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
13 The chief of staff ensures providers reconcile medication information and resolve discrepancies and monitors the providers’ compliance.
Closure Date:
14 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
15 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 compliance.
Closure Date:
16 The chief of staff ensures that a backup call schedule is maintained for urgent care center providers and monitors compliance.
Closure Date:
17 The facility director ensures that support services necessary to care for patients are readily available to the urgent care center during all hours of operation and monitors compliance.
Closure Date:
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| 19-00013-15 | Comprehensive Healthcare Inspection of the Charlie Norwood VA Medical Center, Augusta, Georgia | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that managers consistently implement improvement actions recommended from peer review activities and monitors manager compliance.
Closure Date:
2 The chief of staff ensures that final peer reviews are completed within 120 calendar days from the determination of the need for the review, or there is an extension approved in writing by the director, and monitors compliance.
Closure Date:
3 The facility director makes certain that a summary of the Peer Review Committee’s work is reviewed quarterly by the executive level medical committee and monitors compliance.
Closure Date:
4 The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
Closure Date:
5 The chief of staff makes certain that service chiefs define and communicate expectations for focused professional practice evaluation criteria in advance and maintain appropriate documentation of the processes and monitors service chiefs’ compliance.
Closure Date:
6 The chief of staff ensures that professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
Closure Date:
7 The associate director ensures a clean and safe environment is maintained throughout the facility and monitors team’s compliance.
Closure Date:
8 The associate director ensures the facility maintains an inventory of assets and resources available in the event of a disaster and that it is reviewed annually and monitors compliance.
Closure Date:
9 The associate director validates that the facility’s emergency operations plan includes all required elements and is reviewed annually and monitors compliance.
Closure Date:
10 The facility director makes certain that the controlled substances coordinator submits monthly summary of findings and quarterly trends, that include discrepancies and vulnerabilities, to the director and monitors controlled substances coordinator’s compliance.
Closure Date:
11 The facility director makes certain that the appropriate quality management committee reviews the controlled substances monthly and quarterly reports at least on a quarterly basis and monitors compliance.
Closure Date:
12 The facility director makes certain the controlled substances coordinator conducts required annual competency assessments of the controlled substances inspectors and monitors the coordinator’s compliance.
Closure Date:
13 The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substances in storage areas on the day initiated and monitors inspectors’ compliance.
Closure Date:
14 The facility director makes certain that reconciliation of one day dispensing from pharmacy to every automated dispensing cabinet and one day return of stock to pharmacy from every automated dispensing cabinet is performed during monthly controlled substances area inspections and monitors compliance.
Closure Date:
15 The facility director makes certain the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of controlled substances orders during monthly area inspections and monitors compliance.
Closure Date:
16 The facility director makes certain that controlled substances inspectors verify, during monthly inspections, there is a corresponding sealed evidence bag containing drug(s) for each destruction holding number listed on the “Destructions File Holding Report” and monitors inspector’s compliance.
Closure Date:
17 The facility director ensures that controlled substances inspectors complete verification of prescription pad inventories count during monthly pharmacy inspections and monitors inspectors’ compliance.
Closure Date:
18 The facility director ensures that the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances prescriptions during monthly area inspections and monitors inspectors’ compliance.
Closure Date:
19 The facility director makes certain that controlled substances inspectors complete the verification of the 72-hour inventory and monitors inspectors’ compliance.
Closure Date:
20 The chief of staff ensures providers complete mandatory military sexual trauma training within the required time frame and monitors providers’ compliance.
Closure Date:
21 The facility director confirms that the committee responsible for Women Veterans Subcommittee meets quarterly and includes required core members and monitors committee’s compliance.
Closure Date:
22 The facility director ensures that assigned staff implement a process to track and follow-up on findings from cervical cancer screenings and monitors staff’s compliance.
Closure Date:
23 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
24 The chief of staff ensures that a backup call schedule is maintained for emergency department providers and monitors the department’s compliance.
Closure Date:
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| 18-06294-213 | VHA Did Not Effectively Manage Appeals of Non VA Care Claims | Audit | ||
1 The Under Secretary for Health ensure the Payment Operations and Management directorate identifies its facilities that receive appeals but do not have sufficient staff assigned to process them, and then promptly transfers unprocessed appeals from those facilities to a Payment Operations and Management appeals-processing facility to ensure they are processed.
Closure Date:
2 The Under Secretary for Health ensure the Payment Operations and Management directorate updates communications to direct claimants to submit appeals to its facilities with designated appeals-processing staff.
Closure Date:
3 The Under Secretary for Health clearly define the roles and responsibilities of an accountable OCC official to oversee the Payment Operations and Management directorate’s appeals function.
Closure Date:
4 The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates effective policies and procedures for its staff to promptly process their pending appeals workload.
Closure Date:
5 The Under Secretary for Health ensure the Payment Operations and Management directorate completely and accurately identifies and records its pending appeals inventory in a standard system of record and implements controls to effectively maintain the pending appeals inventory in the system of record.
Closure Date:
6 The Under Secretary for Health ensure all Payment Operations and Management directorate appeals processors obtain access to Caseflow promptly, and that Caseflow includes fields that are necessary to effectively manage Payment Operations and Management appeals.
Closure Date:
7 The Under Secretary for Health ensure the Payment Operations and Management directorate implements and communicates to all staff effective policies and procedures for processing and managing appeals under the new appeals process, including timeliness standards.
Closure Date:
8 The Under Secretary for Health ensure the Payment Operations and Management directorate completes a comprehensive assessment of its appeals workforce and inventory, and then reevaluates its appeals staffing needs.
Closure Date:
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| 18-04675-23 | Comprehensive Healthcare Inspection of the VA Connecticut Healthcare System, West Haven, Connecticut | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that service chiefs clearly define and share in advance the expectations for the focused professional practice evaluation process with providers and monitors the service chiefs’ compliance.
Closure Date:
2 The chief of staff ensures that service chiefs include service/section-specific criteria in ongoing professional practice evaluations and monitors service chiefs’ compliance.
Closure Date:
3 The chief of staff ensures that service chiefs’ determination to continue current privileges is based, in part, on results of ongoing professional practice evaluation activities and monitors service chiefs’ compliance.
Closure Date:
4 The facility director ensures that the Medical Staff Executive Council documents consideration of focused and ongoing professional practice evaluation results in its decision to recommend approval of requested privileges and monitors the Medical Staff Executive Council’s compliance.
Closure Date:
5 The facility director makes certain that an adequate number of controlled substances inspectors are appointed in writing prior to performing inspector duties to a term not to exceed three years and monitors the compliance.
Closure Date:
6 The facility director ensures that a controlled substances inspector does not inspect the same controlled substances area for two consecutive months and monitors inspectors’ compliance.
Closure Date:
7 The facility director ensures that monthly reconciliation of one-day’s dispensing from pharmacy to every automated dispensing cabinet and one-day’s return of stock to pharmacy from every automated dispensing cabinet is performed during controlled substances inspections and monitors compliance.
Closure Date:
8 The facility director ensures that the controlled substances coordinator refrains from conducting routine inspections of controlled substance storage areas and monitors inspector’s compliance.
Closure Date:
9 The facility director makes certain that the nursing staff complete the review of automatic dispensing cabinets’ override reports and monitors the program staff’s compliance.
Closure Date:
10 The facility director confirms that primary care and mental health 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 and assess understanding of education provided specific to newly prescribed medications and monitors clinicians’ compliance.
Closure Date:
12 The chief of staff ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health records and monitors clinicians’ compliance.
Closure Date:
13 The chief of staff ensures providers communicate abnormal cervical pathology results to patients within the required time frame and monitors providers’ compliance.
Closure Date:
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| 19-00075-14 | Deficiencies in Sterile Processing Services and Decreased Surgical Volume at the VA Connecticut Healthcare System, Newington and West Haven, Connecticut | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 1 Director provides oversight for the timely implementation of Office of Inspector General recommendations directed to the VA Connecticut Healthcare System Director.
Closure Date:
2 The Veterans Integrated Service Network 1 Director ensures the timely completion of hiring actions at the VA Connecticut Healthcare System until staffing deficiencies in Sterile Processing Services and Facility Management Services are fully resolved.
Closure Date:
3 The VA Connecticut Healthcare System Director ensures clinical leaders with working knowledge of and/or expertise in operating room, surgery, and Sterile Processing Services are included in the decision-making and resolution of Sterile Processing Service remediation efforts.
Closure Date:
4 The VA Connecticut Healthcare System Director ensures the development and implementation of a clear action plan to establish communication, foster collaboration, and restore system staff trust in system leaders, and, as necessary, consult with Veterans Health Administration’s National Center for Organizational Development.
Closure Date:
5 The VA Connecticut Healthcare System Director provides oversight for the timely completion of the projects impacting Sterile Processing Services and Surgical Services that remain pending.
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6 The VA Connecticut Healthcare System Director ensures that the development, review, and revision of standard operating procedures is completed, and that a sustainable process is in place to maintain standard operating procedures.
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7 The VA Connecticut Healthcare System Director ensures that all Sterile Processing Services staff complete and maintain Sterile Processing Services training and competencies.
Closure Date:
8 The VA Connecticut Healthcare System Director ensures that Sterile Processing Services leaders maintain a staffing plan that includes an accurate number of authorized positions that is based on clinical and administrative workload and other appropriate measures, and includes contingencies for staffing areas with high attrition rates.
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9 The VA Connecticut Healthcare System Director ensures that surgery and anesthesia staff evaluate the readiness of all supplies and equipment for use before anesthetizing a patient.
Closure Date:
10 The VA Connecticut Healthcare System Director evaluates and reports the impact on and identified needs of the VA Connecticut Healthcare System residency program.
Closure Date:
11 The VA Connecticut Healthcare System Director works collaboratively with Veterans Integrated Service Network 1 Director to ensure the timely implementation of future Sterile Processing Services planned projects.
Closure Date:
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| 19-00002-16 | Two Patient Suicides, a Patient Self-Harm Event, and Mental Health Services Administrative Deficiencies at the Alaska VA Healthcare System, Anchorage, Alaska | Hotline Healthcare Inspection | ||
1 The Alaska VA Healthcare System Director ensures that staff are educated and trained on missing patient policies and procedures, and monitors compliance.
Closure Date:
2 The Alaska VA Healthcare System Director makes certain that managers establish a unified Same Day Access Clinic policy, educates staff on the policy, and monitors compliance.
Closure Date:
3 The Alaska VA Healthcare System Director ensures a psychiatric coverage plan for the Same Day Access Clinic for all hours of operation that includes a contingency plan for psychiatric providers’ unavailability.
Closure Date:
4 The Alaska VA Healthcare System Director establishes clearly defined Same Day Access Clinic hours that are consistent with the Same Day Access Clinic policy and signage.
Closure Date:
5 The Northwest Network Director strengthens the Alaska VA Healthcare System leaders’ adherence to the scheduling directive reporting structure as required by the Veterans Health Administration.
Closure Date:
6 The Alaska VA Healthcare System Director implements standardized clinically indicated date and return to clinic order procedures, and staff training, and monitors for compliance.
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7 The Alaska VA Healthcare System Director establishes a missed appointment policy, ensures that staff are educated on the policy, and monitors compliance.
Closure Date:
8 The Alaska VA Healthcare System Director facilitates the full implementation of a Behavioral Health Interdisciplinary Program, as required by the Veterans Health Administration.
Closure Date:
9 The Alaska VA Healthcare System Director ensures staff training on the Mental Health Treatment Coordinator policy established on February 1, 2019, and monitors compliance.
Closure Date:
10 The Alaska VA Healthcare System Director establishes a behavioral health emergency policy, ensures that staff are educated on the policy, and monitors compliance.
Closure Date:
11 The Northwest Network Director ensures that the Alaska VA Healthcare System Director evaluates the culture, morale, and leadership issues identified by the alternative dispute resolution specialist in this report and takes appropriate action as necessary.
Closure Date:
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14957