Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-01879-232 | Alleged Poor Quality of Cancer Care at the VA Caribbean Healthcare System, San Juan, Puerto Rico | Hotline Healthcare Inspection | ||
1 The VA Caribbean Healthcare System Director strengthens procedures to ensure that medical oncology staff monitor patients receiving chemotherapy to assess for toxicity symptoms and patient tolerance, and the monitoring is documented in the electronic health record.
Closure Date:
2 The VA Caribbean Healthcare System Director ensures that program managers assess the need for care coordination agreements between the community living center and specialty services and, if warranted, implement the agreement(s).
Closure Date:
3 The VA Caribbean Healthcare System Director partners with community living center managers to provide education to nursing staff on the communication of patient status changes using the observation and communication tool, and procedures as outlined in VA Caribbean Healthcare System policy.
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4 The VA Caribbean Healthcare System Director makes certain that community living center managers conduct a review of patient care plans to confirm their accuracy, update them as necessary, and strengthen processes to prevent future omissions as warranted.
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5 The VA Caribbean Healthcare System Director verifies that primary care physicians receive the education on the management of patients with prostate cancer being provided to urology and radiation oncology physicians.
Closure Date:
6 The VA Caribbean Healthcare System Director ensures that the findings identified by Veterans Integrated Service Network reviewers as noted in this report are addressed and resolved.
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7 The Veterans Integrated Service Network 8 Director makes certain that consistent and clear instructions are provided for all management reviews conducted concurrently by independent reviewers.
Closure Date:
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| 18-04681-228 | Comprehensive Healthcare Inspection of the Sheridan VA Medical Center, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures that clinical managers define and communicate expectations for focused professional practice evaluations in advance and maintain appropriate documentation of the processes, and monitors the clinical managers’ compliance.
Closure Date:
2 The chief of staff ensures ongoing professional practice evaluations include service-specific criteria and monitors compliance.
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3 The chief of staff makes certain that service chiefs collect and review ongoing professional practice evaluation data and that the facility’s Executive Committee of the Medical Staff reviews the data in the consideration to continue provider privileges, and monitors compliance.
Closure Date:
4 The chief of staff confirms that the solo pathologist’s ongoing professional practice evaluation includes the minimum required specialty criteria and monitors compliance.
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5 The associate director validates that the environment of care rounds team is trained to identify and record all environment of care deficiencies during environment of care rounds, and monitors compliance.
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6 The facility director works with the VISN director and contracting officer to make certain that the Rock Springs VA Clinic property owners correct deficiencies and monitors compliance.
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7 The associate director ensures the VA police document response time to panic alarm testing at the locked inpatient mental health unit and monitors compliance.
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8 The associate director ensures flooring that provides cushioning is installed in the mental health seclusion rooms.
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9 The associate director validates that the facility’s emergency operations plan includes all required elements and monitors compliance.
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10 The associate director makes certain that monthly emergency generator testing includes documentation of dynamic load used and monitors compliance.
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11 The facility director makes certain that monthly 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 controlled substances inspections and monitors compliance.
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12 The facility director ensures that controlled substances inspectors verify controlled substances orders on a monthly basis and monitors the inspectors’ compliance.
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13 The facility director affirms that controlled substances coordinators refrain from conducting routine inspections and monitors the coordinators’ compliance.
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14 The facility director makes certain that providers complete military sexual trauma mandatory training within the required time frame and monitors compliance.
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15 The chief of staff ensures clinicians provide and document patient/caregiver education for newly prescribed medications and monitors the clinicians’ compliance.
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16 The facility director ensures the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
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17 The facility director must seek a waiver should the facility continue to operate the urgent care center 24 hours a day, seven days a week.
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18 The facility director ensures that the urgent care center is staffed with a licensed physician and a minimum of two registered nurses at all times of operation and monitors compliance.
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19 The chief of staff ensures that a backup call schedule is maintained for urgent care providers and monitors compliance.
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20 The chief of staff ensures the emergency department integration software tracking program is fully implemented for data entry and that the information is utilized for improvement and monitors compliance.
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21 The facility director ensures appropriate signage directs patients to the urgent care center and monitors compliance.
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22 The facility director ensures that equipment and supplies necessary to care for patients are readily available at all times in the urgent care center and monitors compliance.
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| 18-01944-214 | Construction Project Management at the Ralph H. Johnson VA Medical Center in Charleston, South Carolina | Review | ||
1 The OIG recommended the director of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina, ensure a process is established requiring that the Veterans Integrated Service Network 7 capital asset manager be informed, prior to construction contact awards, if construction is not planned to start within 150 days after contract awards, so that prudent decisions can be made in a timely manner regarding project funds.
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| 19-06565-217 | Workload Management Challenges Identified at the Salt Lake City, Utah, Fiduciary Hub | Review | ||
1 The Director of the Salt Lake City Regional Office ensures the Fiduciary Hub workload management plan establishes timeliness goals for the various action mail tasks.
2 The Director of the Salt Lake City Regional Office makes certain fiduciary hub managers measure performance and monitor adherence to timeliness goals for action mail tasks once established.
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3 The Director of the Salt Lake City Regional Office establishes a requirement within the Fiduciary Hub workload management plan for routinely reviewing and resolving duplicate action mail tasks.
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| 19-06429-227 | Leadership Failures Related to Training, Performance, and Productivity Deficits of a Provider at a Veterans Integrated Service Network 10 Medical Facility | Hotline Healthcare Inspection | ||
1 The Veteran Integrated Service Network 10 Medical Facility Director ensures the Credentialing and Privileging process for primary source verification of foreign education is performed and documented in accordance with Veterans Health Administration requirements.
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2 The Veteran Integrated Service Network 10 Medical Facility Director ensures that the Credentialing and Privileging process for verifying and accepting professional references meets sufficiency standards in accordance with Veterans Health Administration guidance.
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3 The Veteran Integrated Service Network 10 Medical Facility Director ensures that the Focused Professional Practice Evaluation process used to determine technical competence and skills meets Veterans Health Administration requirements.
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4 The Veteran Integrated Service Network 10 Director evaluates whether the decision to reappoint the surgeon referenced in this report was improperly influenced by the Chief of Staff’s resolve to retain the services of the surgeon’s spouse in a sub-specialty position, and take action, if indicated.
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5 The Veteran Integrated Service Network 10 Medical Facility Director coordinates with Veterans Integrated Service Network 10 or other resources to assist and support sole providers with performance deficits.
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| 18-06510-222 | Comprehensive Healthcare Inspection of the Eastern Oklahoma VA Health Care System, Muskogee, Oklahoma | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that ongoing professional practice evaluations are completed by providers with similar training and privileges and monitors compliance.
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2 The chief of staff makes certain that all focused professional practice evaluations include clearly defined time limitations and monitors compliance.
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3 The chief of staff confirms that clinical managers share in advance the expectations and outcomes for focused professional practice evaluations for cause with providers and monitors clinical managers’ compliance.
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4 The associate director confirms that unit supervisors remove clean and sterile packaged items from shipping cartons and corrugated boxes prior to stowing in clean or sterile storage areas and monitors unit supervisors’ compliance.
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5 The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related information to leadership and monitors coordinator’s compliance.
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6 The facility director ensures that the military sexual trauma coordinator tracks and monitors the screening, referral, and treatment services provided to veterans and monitors coordinator’s compliance.
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7 The facility director confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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8 The chief of staff makes certain that clinicians provide education to the patient and/or caregiver about the risks/benefits, potential interactions, and side effects of newly prescribed medications and monitors clinicians’ compliance.
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9 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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10 The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
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11 The facility director makes certain that the Women Veterans Health Committee reports at least quarterly to the Medical Executive Committee.
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| 18-02830-164 | State Prescription Drug Monitoring Programs Need Increased Use and Oversight | Audit | ||
1 Develop national processes to oversee medical facility compliance with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, and coordinate the possible automated information technology solutions and inter-office and -disciplinary communications necessary to improve prescription drug monitoring program monitoring and usage in Veterans Health Administration.
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2 Update the Pain Management and Opioid Safety training course to specifically address VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, query requirements and recommendations.
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3 Ensure VA clinicians who prescribe opioids take the Pain Management and Opioid Safety training once, with annual refresher training.
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4 Add an addendum to VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, that references the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain and ensure VA clinicians are educated and receive annual training on the Clinical Practice Guideline, to include the Centers for Disease Control and Prevention’s recommended frequency for prescription drug monitoring program queries based on the patients’ risk factors.
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5 Direct Veterans Integrated Service Networks and their VA medical facilities to ensure local policies are consistent with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs.
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6 Develop automated information technology solutions to facilitate clinicians’ access toprescription drug monitoring program query information and reinforce the need tocomplete minimum annual VA-required prescription drug monitoring program queries.
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7 Ensure non-VA care clinicians are in good standing and have a current state medical license that requires adherence to their state’s prescription drug monitoring program query requirements; adhere to the Veterans Affairs Opioid Safety Initiative Guidelines, including guidelines for prescription drug monitoring program queries; and are monitored to ensure appropriate corrective actions are taken if their prescribing practices are found to be inconsistent with VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
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8 Ensure Veterans Integrated Service Networks implement an effective prescription drug monitoring program oversight process that includes the review of compliance rates with medical facility directors.
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| 18-03526-230 | Alleged Care Delays and Inadequate Instrument Precleaning at the New Mexico VA Health Care System, Albuquerque | Hotline Healthcare Inspection | ||
1 The New Mexico VA Health Care System Director ensures that patients denied a Veterans Choice Program referral are informed of their rights to appeal, that facility policy is consistent with Veterans Health Administration requirements, and monitors compliance.
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2 The New Mexico VA Health Care System Director verifies that the Ophthalmology and Optometry Departments’ consult management and scheduling practices are consistent with Veterans Health Administration patient indicated date timeframe requirements, incorporates patient preference, and includes receiving provider review of consults, and monitors compliance.
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3 The New Mexico VA Health Care System Director makes certain the Ophthalmology and Optometry Departments’ clinical and administrative staff receive training regarding Veterans Health Administration requirements of consult management and scheduling practices.
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4 The New Mexico VA Health Care System Director reviews the Ophthalmology Department’s eye cataract intake surgery scheduling practice and ensures that overall timeliness is consistent with Veterans Health Administration directives, and monitors compliance.
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5 The New Mexico VA Health Care System Director conducts a timeliness review of the authorization process for non-VA Care routine eye appointments, including diabetic eye examinations, and implement action plans if the process fails to adhere to Veterans Health Administration directives.
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6 The New Mexico VA Health Care System Director ensures the Gastroenterology Department’s consult management practices are consistent with Veterans Health Administration scheduling requirements for patient indicated dates, and monitors compliance.
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7 The New Mexico VA Health Care System Director establishes a routine review of Gastroenterology Department consult performance measures and a method to monitor identified deficiencies consistent with Veterans Health Administration requirements.
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8 The New Mexico VA Health Care System Director evaluates whether test results within the past 12 months, ordered by the Gastroenterology Department were communicated to patients according to Veterans Healthcare Administration and facility policy, and takes action as necessary based on the results of the evaluation.
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9 The New Mexico VA Health Care System Director reviews facility policy for the ordering and reporting of test results to be in alignment with Veterans Health Administration directives and completes revisions, if needed.
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10 The New Mexico VA Health Care System Director ensures that Gastroenterology Department-ordered test results are communicated timely in accordance with Veterans Health Administration and facility policy and the timeliness is monitored through the ongoing peer review process as required by facility policy.
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11 The New Mexico VA Health Care System Director ensures that the Gastroenterology Department Service Chief develop a process for delegating responsibility and accountability for test results and follow-up when multiple providers are involved, and monitors compliance.
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12 The New Mexico VA Health Care System Director ensures documented endoscope precleaning training for Gastroenterology Fellows, and monitors compliance.
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13 The New Mexico VA Health Care System Director verifies that documentation of endoscope precleaning competencies for Gastroenterology Fellows is consistent with Veterans Health Administration requirements.
Closure Date:
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| 19-07350-192 | Boston, Massachusetts, VA Regional Office Supervisor Incorrectly Processed Work Items | Review | ||
1 The director of the Boston VA Regional Office reviews and corrects all work items that were cancelled or cleared by the supervisor that are likely to result in adjustments to recipients’ benefit payments.
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2 The director of the Boston VA Regional Office confers with regional counsel to determine the appropriate administrative action to take, if any, against the supervisor.
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3 The director of the Boston VA Regional Office implements a plan to ensure internal controls for assessing the quality of claims processed by supervisors.
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| 18-00777-224 | Quality of Care and Patient Safety Concerns on the Acute Behavioral Health Unit at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania | Hotline Healthcare Inspection | ||
1 The Corporal Michael J. Crescenz VA Medical Center Director ensures that providers understand the importance of monitoring for cardiac changes, drug-drug interactions, and signs of oversedation when initiating patients on methadone.
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2 The Corporal Michael J. Crescenz VA Medical Center Director monitors that providers and clinical staff effectively and directly communicate with one another when providing complex patient care.
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3 The Corporal Michael J. Crescenz VA Medical Center Director confirms that the issue brief submitted on the identified patient contains accurate information.
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4 The Corporal Michael J. Crescenz VA Medical Center Director reviews the root cause analysis related to the identified patient to determine if the team composition compromised the integrity of the root cause analysis and take appropriate action if necessary.
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5 The Corporal Michael J. Crescenz VA Medical Center Director ensures that root cause analysis team compositions include appropriate staff and monitor compliance.
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6 The Corporal Michael J. Crescenz VA Medical Center Director considers Peer Review for Quality Management for the additional two providers identified in this report.
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7 The Corporal Michael J. Crescenz VA Medical Center Director ensures that Unit 7E staff are knowledgeable of the observation policy, and nursing leaders are monitoring staff compliance when assigned rounding responsibilities.
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8 The Corporal Michael J. Crescenz VA Medical Center Director completes actions initiated or taken to resolve identified deficiencies that contributed to the events discussed in this report, and monitors for compliance.
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9 The Corporal Michael J. Crescenz VA Medical Center Director certifies that providers receive ongoing education on the required elements of a signed written consent prior to the initiation of methadone and ensures that providers comply with VA policy and monitors for compliance.
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14957