Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 19-00010-237 | Comprehensive Healthcare Inspection of the North Florida/South Georgia Veterans Health System, Gainesville, Florida | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures all required representatives participate in the interdisciplinary review of utilization management data and monitors representatives’ 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 and monitors patient safety manager’s compliance.
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3 The facility director ensures that the identified committee reviews all resuscitative episodes and monitors the committee’s compliance.
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4 The chief of staff ensures that clinical managers clearly define focused professional practice evaluation criteria in advance with providers and monitors clinical managers’ compliance.
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5 The chief of staff confirms that clinical managers include service/section-specific criteria in ongoing professional practice evaluations and monitors compliance.
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6 The chief of staff makes certain that service chiefs’ determination to recommend continuation of privileges be based in part on results of ongoing professional practice activities and monitors service chiefs’ compliance.
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7 The deputy director confirms that facility managers maintain a safe and clean environment throughout the healthcare system and monitors compliance.
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8 The deputy director ensures the furnishings in the intensive care units are repaired or replaced and monitors compliance.
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9 The deputy director makes certain that medical biohazardous waste storage rooms are secured and properly identified and monitors compliance.
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10 The deputy director makes certain that facility management service managers conduct weekly generator testing as required and monitors managers’ compliance.
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11 The facility director makes certain that controlled substances inspectors complete the monthly controlled substances inspections and physical inventory counts on the day initiated and that the controlled substances coordinator evaluates and maintains supporting documentation and monitors inspectors’ and coordinator’s compliance.
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12 The facility director ensures controlled substances inspectors do not inspect the same area for two or more consecutive months and monitors inspectors’ compliance.
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13 The facility director makes certain the controlled substances coordinator ensures that written and electronic controlled substance orders have been verified and monitors coordinator’s compliance.
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14 The facility director ensures that controlled substances inspectors verify there is a corresponding sealed evidence bag containing drug(s) for each medication listed on the “Destructions File Holding Report” during monthly inspections and monitors inspectors’ compliance.
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15 The facility director ensures that controlled substances inspectors complete pharmacy prescription pad inventories during monthly pharmacy inspections and monitors inspectors’ compliance.
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16 The facility director ensures the controlled substances inspectors verify evidence of written signature for non-electronic controlled substances orders during monthly area inspections and monitors inspectors’ compliance.
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17 The facility director makes certain that controlled substances inspectors complete the verification of the twice weekly pharmacy inventory as required and monitors inspectors’ compliance.
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18 The chief of staff confirms that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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19 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 monitors clinicians’ compliance.
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20 The chief of staff ensures clinicians reconcile medication information and maintain accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
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21 The facility director makes certain that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
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22 The facility director confirms that the Women Veterans Health Committee reports to an executive leadership committee and monitors the committee’s compliance.
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23 The chief of staff ensures that staff collect and track cervical cancer screening data and monitors staff compliance.
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24 The facility director makes certain that the emergency department has on-call social work staff available to assist with patient care and monitors staff compliance.
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25 The facility director confirms adequate directional signage leads patients to the emergency department and monitors staff compliance.
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26 The facility director ensures the chief of Health Information Management facilitates the timely scanning of clinical reports into patients’ electronic health records and monitors compliance.
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27 The deputy director ensures medical equipment is evaluated per manufacturers’ recommendations and monitors compliance.
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28 The deputy director ensures that full and empty oxygen gas cylinders are physically separated and clearly labeled and monitors compliance.
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| 18-04679-239 | Comprehensive Healthcare Inspection of the Hunter Holmes McGuire VA Medical Center, Richmond, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff ensures physician utilization management advisors consistently document their decisions in the National Utilization Management Integration database and monitors advisors’ compliance
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2 The facility director confirms that the patient safety manager includes all required content in root cause analyses and monitors patient safety manager’s compliance.
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3 The facility director makes certain the Code Blue Committee reviews each resuscitative episode under the facility’s responsibility and monitors Code Blue Committee’s compliance.
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4 The chief of staff ensures that clinical managers initiate focused professional practice evaluations that include clearly delineated criteria and time frames in advance and monitors clinical managers’ compliance.
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5 The chief of staff ensures that focused professional practice evaluations are completed by a provider with similar training and privileges and monitors compliance.
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6 The chief of staff makes certain that the Medical Professional Standards Committee reviews and evaluates licensed independent practitioners’ professional practice evaluations when recommending approval of privileges through the Medical Executive Council to the director and monitors committee’s compliance.
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7 The chief of staff ensures that service chiefs consistently collect and review ongoing professional practice evaluation data and monitors service chiefs’ compliance.
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8 The associate director ensures that a safe and clean environment is maintained throughout the facility and monitors compliance.
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9 The facility director makes certain that the controlled substance inspectors conduct the monthly inventories of controlled substances and the controlled substances coordinator maintains supporting documentation of the completion of the monthly inventory of controlled substances and monitors compliance.
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10 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 compliance.
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11 The facility director makes certain that controlled substances inspectors complete the pharmacy monthly controlled substances inspection inventory on the day initiated and monitors inspectors’ compliance.
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12 The facility director makes certain that during monthly inspections, controlled substances inspectors verify that each medication listed on the “Destructions File Holding Report” is contained in a corresponding sealed evidence bag and monitors compliance of controlled substance inspection staff.
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13 The facility director ensures that controlled substances inspectors and coordinator carry out all responsibilities for the verification of pharmacy prescription pad counts during monthly pharmacy inspections and monitors controlled substances inspections staff compliance.
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14 The facility director ensures the controlled substances inspectors and coordinator carry out all required responsibilities for the verification of written controlled substances prescriptions during monthly area inspections and monitors compliance.
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15 The facility director makes certain that controlled substances inspectors and coordinator carry out responsibilities for the 72-hour pharmacy inventory checks as required and monitors compliance.
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16 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required time frame and monitors providers’ compliance.
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17 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 compliance.
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18 The chief of staff ensures clinicians review and reconcile medications and monitors clinicians’ compliance.
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19 The facility director makes certain that the women veterans program manager position is full time and monitors compliance.
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20 The chief of staff ensures the emergency department has an independent licensed mental health provider available as required for 1a facilities and monitors compliance.
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21 The chief of staff ensures that sufficient signage assists and directs patients in locating the emergency department and monitors compliance.
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| 19-00057-238 | Comprehensive Healthcare Inspection of the Tuscaloosa VA Medical Center, Alabama | Comprehensive Healthcare Inspection Program | ||
1 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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2 The facility director requires the patient safety manager to ensure completion of the required minimum of eight root cause analyses each fiscal year and monitors patient safety manager’s compliance.
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3 The facility director makes certain that the patient safety manager or designee includes all the required elements in root cause analyses and monitors patient safety manager’s compliance.
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4 The facility director ensures that managers consistently implement improvement actions arising from root cause analysis activities and evaluate actions taken for sustained improvement and monitors compliance.
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5 The facility director ensures the patient safety manager or designee provides feedback to individuals or departments who submit patient safety incidents that result in root cause analysis and monitors patient safety manager compliance.
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6 The chief of staff ensures ongoing professional practice evaluations utilize assessments by providers with similar training and privileges and monitors compliance.
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7 The associate director ensures that a safe and clean environment is maintained throughout the facility and Selma VA Clinic and monitors compliance.
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8 The associate director ensures the VA police respond to panic alarm testing in the locked mental health unit and document response time and monitors compliance.
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9 The associate director ensures that the comprehensive emergency management plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors 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 ensures clinicians review and reconcile patients’ medications and maintain and communicate accurate patient medication information in patients’ electronic health record and monitors clinicians’ compliance.
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12 The director makes certain that the chief of staff assigns a women’s health medical director or clinical champion and monitors chief of staff’s compliance.
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13 The chief of staff confirms that the Women Veterans Health Committee includes required core members and monitors committee’s compliance.
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14 The chief of staff ensures that providers notify patients of abnormal cervical pathology results within the required time frame and monitors providers’ compliance.
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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.
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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.
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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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| 19-00260-215 | Equipment and Supply Mismanagement at the Hampton VA Medical Center, Virginia | Review | ||
1 Assign a room number and designate a custodial officer to the second-floor operating room storage location and allocate responsibility to identify inventory and update the equipment inventory listing for the appropriate medical center services.
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2 Ensure barcodes are affixed to all storage locations and items to properly track and identify nonexpendable equipment.
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3 Verify and update the information in the Automated Engineering Management System/Medical Equipment Reporting System to ensure all equipment in the second-floor operating room storage location is entered into the system and has accurate item status and location.
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4 Ensure Logistics Service management complies with requirements for completion of reports of survey for equipment identified as lost or stolen.
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5 Develop and implement a process to ensure Logistics Service staff adhere to requirements for proper disposal of equipment that is no longer needed.
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6 Ensure Logistics Service staff use the auto-generate function within the Generic Inventory Package to identify the appropriate quantities for supply orders.
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7 Require Logistics Service management to conduct monthly verifications of the Generic Inventory Package reports to ensure staff use of the system for the receipt and distribution of supplies.
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8 Ensure barcodes are affixed to all storage locations, storage shelves, and bins to properly track and identify expendable supplies.
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9 Ensure Logistics Service management monitors and reviews the weekly verification of expired inventory and ensures log sheets are properly annotated and maintained.
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10 Ensure a staffing plan is implemented to continue filling vacancies based on clinical and administrative workload and includes contingencies for any positions with high turnover rates.
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11 Ensure national requirements for ordering procedures are strictly followed to ensure requestor, approving authority, and receiver for all purchases are not the same individual.
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12 Implement a process to sufficiently and timely address and correct deficiencies identified during the Veterans Integrated Service Network quality control reviews.
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| 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.
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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).
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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.
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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.
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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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