Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-04924-112 | Program of Comprehensive Assistance for Family Caregivers: Timely Discharges, But Oversight Needs Improvement | Audit | ||
1 The Under Secretary for Health establishes processes to conduct matching, at least quarterly, of the records of enrolled veterans and their caregivers against the Department of Veterans Affairs’ death, incarceration, and hospitalization data to help ensure timely program discharges and to reduce the risk of improper and questionable payments.
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2 The Under Secretary for Health takes steps to outline in the program’s roles and responsibilities document what the veteran and caregiver responsibilities are for promptly notifying caregiver support coordinators of deaths.
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3 The Under Secretary for Health institutes a program working group to clarify inconsistencies and gaps in program guidance. Specifically, the working group should determine if incarcerated or hospitalized veterans or caregivers should adhere to different discharge requirements. The working group should also consider the time frames for discharges, a process for veterans and caregivers to reapply to or be suspended from the program following a discharge due to incarceration or hospitalization, and should initiate updating program guidance accordingly.
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| 19-00007-168 | Comprehensive Healthcare Inspection of the Amarillo VA Health Care System, Texas | Comprehensive Healthcare Inspection Program | ||
1 The chief of staff makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors the representatives’ compliance.
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2 The chief of staff ensures the Cardio Resuscitation Committee reviews each resuscitative episode for which the facility is responsible and monitors the committee’s compliance.
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3 The chief of staff ensures that provider privileges contain a clearly delineated timeframe not to exceed two years and monitors compliance.
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4 The chief of staff makes certain that service chiefs establish and define focused professional practice evaluation criteria that include the minimum required specialty criteria, as applicable, prior to initiation of the evaluations and monitors service chiefs’ compliance.
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5 The chief of staff confirms that service chiefs initiate and complete focused professional practice evaluations that include clearly delineated timeframes and monitors service chiefs’ compliance.
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6 The chief of staff ensures that the Medical Executive Board documents consideration of focused professional practice evaluation results in its decision to recommend approval of requested privileges and monitors the Medical Executive Board’s compliance.
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7 The chief of staff confirms that service chiefs include the review of service-specific data for ongoing professional practice evaluations and monitors service chiefs’ compliance.
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8 The chief of staff makes certain that service chiefs consistently collect and review ongoing professional practice evaluation data and monitors service chiefs’ compliance.
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9 The chief of staff ensures that the Medical Executive Board documents its decision to recommend continuing privileges based on ongoing professional practice evaluation results and monitors the board’s compliance.
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10 The associate director ensures staff store expired medications separately from medications available for administration and label medication vials with an expiration date upon opening and monitors staff’s compliance.
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11 The associate director ensures that staff store clean and dirty medical equipment and supplies separately and monitors compliance.
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12 The associate director ensures that managers test all emergency power outlets and monitors managers’ compliance.
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13 The chief of staff ensures the military sexual trauma coordinator tracks military sexual trauma-related staff training and monitors the coordinator’s compliance.
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14 The chief of staff ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related information to leaders and monitors the coordinator’s compliance.
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15 The chief of staff ensures providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
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16 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 the clinicians’ compliance.
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17 The facility director confirms that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
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18 The chief of staff makes certain that program managers implement a process to track results reporting and follow-up care data for cervical cancer screenings and monitors program managers’ compliance.
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19 The chief of staff ensures that ordering providers communicate abnormal results to patients within the required timeframe and monitors providers’ compliance.
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| 18-04680-162 | Comprehensive Healthcare Inspection of the Cheyenne VA Medical Center, Wyoming | Comprehensive Healthcare Inspection Program | ||
1 The facility director ensures the interdisciplinary group or committee that reviews utilization management data includes a representative from the chief business office revenue utilization review and monitors the committee’s compliance.
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2 The facility director ensures the patient safety manager includes all required review elements in root cause analyses and monitors the patient safety manager’s compliance.
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3 The facility director confirms that the Critical Care Committee conducts a complete analysis of resuscitation episodes by reviewing required elements and monitors the committee’s compliance.
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4 The chief of staff ensures service chiefs collect, review, and use ongoing professional practice evaluation data in the determination to continue current privileges and monitors the service chiefs’ compliance.
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5 The chief of staff makes certain service chiefs include the minimum required specialty-specific criteria for ongoing professional practice evaluations of gastroenterology practitioners and monitors service chiefs’ compliance.
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6 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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7 The associate director ensures managers maintain a safe and clean environment in patient care areas and monitors managers’ compliance.
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8 The associate director ensures managers make personal protective equipment readily accessible to employees at the Rawlins VA Clinic and monitors managers’ compliance.
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9 The associate director makes certain that the hazard vulnerability analysis is reviewed annually and monitors compliance.
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10 The associate director confirms that the emergency operations plan is activated twice a year and monitors compliance.
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11 The facility director ensures the military sexual trauma coordinator establishes and monitors military sexual trauma-related staff training and monitors the coordinator’s compliance.
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12 The facility director ensures the military sexual trauma coordinator communicates the status of military sexual trauma-related services and initiatives with leadership and monitors the coordinator’s compliance.
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13 The facility director makes certain that the military sexual trauma coordinator tracks and monitors military sexual trauma-related data and monitors the coordinator’s compliance.
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14 The chief of staff ensures that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
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15 The chief of staff confirms that clinicians provide and document patient/caregiver education and assess understanding of education provided about newly prescribed medications and monitors clinicians’ compliance.
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16 The facility director makes certain that the Women Veterans Health Committee includes required core members and monitors the committee’s compliance.
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17 The associate director for Patient Care Services makes certain that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.
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| 17-05572-170 | Concerns with Access and Delays in Outpatient Mental Health Care at the New Mexico VA Health Care System, Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 The New Mexico VA Health Care System Director ensures that outpatient mental health scheduling staff receive training to use the electronic wait list as required by Veterans Health Administration and that New Mexico VA Health Care System managers monitor compliance.
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2 The New Mexico VA Health Care System Director reviews clinic cancellation rates and develops action plans to address identified issues.
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3 The New Mexico VA Health Care System Director reviews open and completed consult data as well as new patient data and develops action plans to address identified issues.
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4 The New Mexico VA Health Care System Director evaluates the underutilization of non-VA and telemental health services for the outpatient mental health department and develops an action plan to address identified issues.
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5 The New Mexico VA Health Care System Director ensures that patients with outpatient mental health consults and return-to-clinic orders, including telemental health, are scheduled as required by Veterans Health Administration policy and within the Veterans Health Administration consult/return-to-clinic timeframe and that the scheduling process is monitored for compliance.
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6 The New Mexico VA Health Care System Director and managers review provider and scheduling staffing levels and develop an action plan to address recommendations, if any, from the staffing level reviews.
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7 The New Mexico VA Health Care System Director assesses hiring practices for providers and scheduling staff and ensures positions are filled timely.
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8 The New Mexico VA Health Care System Director updates the New Mexico VA Health Care System policies, Consult Management, and Failure to Report for Scheduled Clinic Appointments, to meet Veterans Health Administration policy.
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9 The New Mexico VA Health Care System Director ensures outpatient mental health staff follow Veterans Health Administration requirements for no-show patients and monitors compliance with this process.
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10 The New Mexico VA Health Care System Director confirms that the Administrative Investigative Board recommendations and action plans are completed as required by VHA and managers monitor compliance.
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11 The New Mexico VA Health Care System Director ensures the Administrative Investigative Board process includes identification of relevant documents, records, and other information pertinent to the issues of an investigation.
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12 The New Mexico VA Health Care System Director evaluates the practice of marking outpatient mental health consults as complete without an appointment and without documenting a mental health risk evaluation and takes action as necessary.
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| 18-04132-163 | Alleged Inadequate Response to a Missing Patient and Safety Concerns at the Bay Pines VA Healthcare System, Florida | Hotline Healthcare Inspection | ||
1 The Bay Pines VA Healthcare System Director develops a policy to address patients with look-alike or soundalike names, educates staff on the use of the policy, and monitors compliance.
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2 The Bay Pines VA Healthcare System Director implements missing patient documentation training for staff, and monitors compliance.
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3 The Bay Pines VA Healthcare System Director ensures that staff responsible for contacting outside facilities for missing patients receive training on their duties and responsibilities, and monitors compliance.
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| 17-05835-165 | Alleged Interference and Failure to Comply with the Pain Management Directive and the Opioid Safety Initiative at the VA Northern Indiana Health Care System, Fort Wayne, Indiana | Hotline Healthcare Inspection | ||
1 The Veteran Integrated Service Network 10 Director ensures a case consult is made to Veterans Health Administration’s National Center for Ethics to consider whether the Chief of Staff used the position of authority in a manner intended to induce a patient management action which would have otherwise not been taken and, if so, whether the Chief of Staff’s conduct comports with a proper ethical standard.
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2 The Northern Indiana Health Care Director verifies that the Pain Management Committee is providing oversight and monitoring of pain management activities as required by Veterans Health Administration policy and monitors compliance.
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3 The Northern Indiana Health Care Director ensures monitoring of the quality of pain assessments and the effectiveness of pain management interventions and monitors compliance.
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4 The Northern Indiana Health Care Director develops and implements a process to evaluate the success of meeting the goals of the Veterans Health Administration National Pain Management Strategy on a regular basis, at least yearly.
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5 The Northern Indiana Health Care Director establishes a formal transfer process for tertiary, interdisciplinary pain rehabilitation program referrals as required by Veterans Health Administration’s stepped care model for pain management.
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6 The Northern Indiana Health Care Director evaluates the educational programs offered to providers related to pain management and opioid safety to determine if the programs meet the intent of the Veterans Health Administration Pain Management Strategy for standardizing training and competencies and ensure that providers attend regularly.
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7 The Northern Indiana Health Care Director ensures that the pain management team is operational as required by Veterans Health Administration.
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8 The Northern Indiana Health Care Director ensures that the system policy is followed for providers to routinely review an opioid risk assessment for patients on long-term opioid therapy and monitors compliance.
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9 The Northern Indiana Health Care Director verifies compliance with the system’s pain management policy regarding patients’ requests to change providers and monitors compliance.
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10 The Northern Indiana Health Care Director makes certain that primary care providers are utilizing the prescription drug monitoring program as required by Veterans Health Administration when prescribing opioid medication and monitors compliance.
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11 The Northern Indiana Health Care Director ensures that primary care providers receive education on safe and effective Veterans Integrated Service Network tapering programs for patients using the combination of benzodiazepines and opioids and monitors compliance.
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12 The Northern Indiana Health Care Director ensures that providers receive education on tapering programs for patients on high-risk opioids and monitors compliance.
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| 19-00497-161 | Leadership, Clinical, and Administrative Concerns at the Charlie Norwood VA Medical Center, Augusta, Georgia | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director evaluates the quality and professionalism of Executive Leadership Team communications and takes action when indicated.
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2 The Veterans Integrated Service Network Director requires the development of, and follow-through on, corrective action plans responding to relevant findings from the National Center of Organizational Development’s 2018 site visits and reports.
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3 The Charlie Norwood VA Medical Center Director develops a process to ensure that Light Electronic Action Framework hiring requests are tracked and processed timely.
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4 The Charlie Norwood VA Medical Center Director reviews the facility’s hiring processes to identify opportunities to improve the efficiency and timeliness of hiring actions, and takes corrective action, as needed.
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5 The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written critical care unit bed management policy that clearly states the process to be followed when an inpatient requires intensive care and a critical care unit bed is unavailable.
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6 The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a written policy regarding patient-owned medical devices and equipment that clearly outlines restrictions and acceptable uses when the patient is hospitalized.
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7 The Charlie Norwood VA Medical Center Director ensures development and broad dissemination of a standardized method for documenting and ensuring compliance with the internal hand-off communication policy.
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8 The Charlie Norwood VA Medical Center Director ensures that neurosurgery privileges are amended to include only procedures which facility infrastructure can support.
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9 The Charlie Norwood VA Medical Center Director ensures that the nurse’s failure related to the computed tomography (CT) event outlined in this report is evaluated and administrative action is taken, as indicated.
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10 The Charlie Norwood VA Medical Center Director enhances processes to document Strategic Analytics for Improvement and Learning related improvement actions.
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11 The Charlie Norwood VA Medical Center Director continues efforts to improve patient and employee satisfaction.
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12 The Charlie Norwood VA Medical Center Director ensures prompt evaluation of sentinel events, to include root cause analyses, in accordance with Veterans Health Administration requirements.
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13 The Charlie Norwood VA Medical Center Director evaluates the documentation failures related to Patient Y, and takes appropriate action, as indicated.
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14 The Charlie Norwood VA Medical Center Director ensures the development of policy addressing the appropriate method for confirming and documenting nasogastric tube placement prior to administration of medications or tube feedings, including actions that should be taken when a nasogastric tube is partially dislodged.
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15 The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to ensure that all registered nurses assigned to work in critical care units promptly complete assessments for missing unit-specific competencies.
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16 The Charlie Norwood VA Medical Center Director requires the Associate Director for Patient and Nursing Services to enhance processes to ensure that nursing competency skills assessments are specific to individual duty assignments and completed in accordance with Veterans Health Administration and facility policy.
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17 The Charlie Norwood VA Medical Center Director ensures that critical care unit staffing decisions include contingencies for staff absences.
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18 The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical care unit and emergency department nurse vacancies, and ensure that until optimal staffing is attained, alternate methods are consistently available to meet patient care needs.
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19 The Charlie Norwood VA Medical Center Director ensures that unexcused nursing absences are managed in accordance with relevant Human Resource guidelines.
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20 The Charlie Norwood VA Medical Center Director ensures that the emergency department security system is upgraded to meet current security requirements and to provide a safe environment for patients and staff.
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21 The Charlie Norwood VA Medical Center Director continues efforts to recruit and hire for critical laboratory staff vacancies, and ensures that until optimal staffing is attained, alternate methods are consistently available that meet patient care needs.
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22 The Charlie Norwood VA Medical Center Director ensures that before policy changes are made that impact the delivery of quality patient care, broad discussion with all key stakeholders takes place and written guidance is widely disseminated.
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23 The Charlie Norwood VA Medical Center Director ensures that policies and procedures regarding the appropriate transfer of critically ill patients are developed in conjunction with key stakeholders and that the process is widely disseminated to relevant staff.
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24 The Charlie Norwood VA Medical Center Director ensures the Contracting Officer’s Representative responsible for the technical administration of the transportation contract conducts surveillance of the contractor’s performance and provides oversight of the contractual agreements.
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25 The Charlie Norwood VA Medical Center Director ensures contingency plans are in place to rapidly mobilize staff when emergency department patients’ care demands exceed the current staffing resources.
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26 The Charlie Norwood VA Medical Center Director ensures there is a signed boarder policy, which is broadly disseminated.
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27 The Veterans Integrated Service Network Director completes an assessment of the facility’s ability to assure consistent availability of services and staffing to support providers’ professional practice and the safe and timely delivery of care, and takes action as necessary.
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| 18-03576-158 | Deficiencies in Discharge Planning for a Mental Health Inpatient Who Transitioned to the Judicial System from a Veterans Integrated Service Network 4 Medical Facility | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director solicits an ethics consult regarding the patient’s final episode of care and treatment course including the failure to inform the patient or family of impending arrest and lack of family inclusion in decision-making.
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2 The Facility Director strengthens inpatient mental health unit processes to include the patient, family members, or surrogate in treatment and discharge planning decisions.
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3 The Facility Director evaluates the inpatient mental health unit assessment practices of patients’ decision-making capacity and voluntary admission status, and takes actions as appropriate.
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4 The Facility Director ensures that facility staff identify and document patients’ surrogates accurately.
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5 The Facility Director ensures that inpatient mental health unit discharge processes include a complete medical and psychiatric diagnostic summary to patients’ receiving mental health providers.
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6 The Facility Director develops inpatient mental health unit discharge processes that include a clinical hand-off communication to patients’ receiving mental health providers.
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7 The Facility Director ensures that a mental health treatment coordinator is assigned for patients during all episodes and levels of mental health care.
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8 The Facility Director ensures that informed consent is obtained from patients or authorized surrogates for release of information as required.
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9 The Facility Director evaluates inpatient mental health unit admission practices and develops processes in compliance with Veterans Health Administration policy regarding voluntary and involuntary admissions.
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10 The Facility Director provides guidance to clinical staff regarding access to consultative resources such as forensic mental health experts, Office of General Counsel, and Ethics Consultation Service.
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| 18-06508-155 | Comprehensive Healthcare Inspection of the James H. Quillen VA Medical Center, Mountain Home, Tennessee | Comprehensive Healthcare Inspection Program | ||
1 The facility director makes certain that controlled substances inspectors complete monthly physical inventories of controlled substance storage areas on the day initiated and monitors the inspectors’ compliance.
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2 The facility director ensures that controlled substances program staff reconcile the restocking/refilling from the pharmacy to every automated dispensing cabinet for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
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3 The facility director ensures that controlled substances program staff reconcile the return of stock from every automated dispensing cabinet to the pharmacy for one random day during monthly controlled substances area inspections and monitors controlled substances program staff’s compliance.
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4 The facility director confirms that controlled substances inspectors complete emergency drug cache inspections and monitors inspectors’ compliance.
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5 The chief of staff makes certain that clinicians provide and document patient/caregiver education specific to the newly prescribed medication and monitors clinicians’ compliance.
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| 17-05859-131 | Management of Major Medical Leases Needs Improvement | Audit | ||
1 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction ensure there are adequate funds available to routinely conduct planning activities, including developing requests for lease proposals, for Strategic Capital Investment Planning approved major leases while waiting for congressional authorization.
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2 The Assistant Secretary for Management and Chief Financial Officer reconsider centralizing major medical lease acquisition funding through VA’s acceptance of the completed building.
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3 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction obtain adequate resources to deliver leases on schedule.
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4 The Assistant Secretary for Management ensure that the prospectus cost estimates provided to Congress are accurate and the costs are allocated appropriately to comply with OMB Circular A-11 requirements.
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5 The Principal Executive Director and Chief Acquisition Officer for the Office of Acquisition, Logistics, and Construction implement a comprehensive VA policy for critical decisions in the lease acquisition process establishing clear lines of authority and allowable time frames.
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6 The Deputy Under Secretary for Health for Operations and Management and the Executive Director, Office of Construction Facilities Management, ensure VA uses appropriate security measure requirements when acquiring VA major medical leases by performing Interagency Security Committee risk evaluations prior to solicitation.
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7 The Executive Director, Office of Construction Facilities Management, ensure project acquisition teams are adequately trained in performance-based acquisition.
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8 The Executive Director, Office of Construction Facilities Management, evaluate the use of consultants in the solicitation development process for Requests for Lease Proposals of major medical leases on a case-by-case basis.
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14957