Recommendations
2111
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-00808-186 | Mismanagement of a Resuscitation and Other Concerns at the Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Hotline Healthcare Inspection | ||
1 The Gulf Coast VA Health Care System Director ensures behavior health staff at the Gulf Coast VA Health Care System follow the Emergency/Code Blue procedures for patients needing resuscitative care and compliance is monitored.
Closure Date:
2 The Gulf Coast VA Health Care System Director ensures behavior health nurses adhere to Veterans Health Administration Directive 2011-016 for pronouncement of deaths.
Closure Date:
3 The Gulf Coast VA Health Care System Director makes certain behavioral health unit nurses maintain basic life support competency and training (certification) and monitors compliance.
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4 The Gulf Coast VA Health Care System Director evaluates the Inpatient Behavioral Health Unit 25-B nurses’ patient health record documentation (including but not limited to the observations every 15-minutes) for accurate and complete statements and takes action as necessary based on the findings.
Closure Date:
5 The Gulf Coast VA Health Care System Director ensures Gulf Coast VA Health Care System policy and providers comply with Veterans Health Administration policy on the documentation requirements of provider to provider communication of transfer of behavioral health patients.
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6 The Gulf Coast VA Health Care System Director reviews the policy and procedure for use of the emergency carts to include checks, expired equipment, and locked drawers and ensures compliance and oversight.
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7 The Veterans Integrated Service Network Director evaluates the recommendations from the fact-finding review and takes action as necessary.
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8 The Gulf Coast VA Health Care System Director complies with Veterans Health Administration policies regarding institutional disclosure.
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9 The Gulf Coast VA Health Care System Director ensures that required documentation is completed on all basic life support events and reviewed by the critical care committee.
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| 18-00469-150 | Non VA Emergency Care Claims Inappropriately Denied and Rejected | Audit | ||
1 The Under Secretary for Health reevaluates all claims denied after April 8, 2016, for the reason of “other health insurance” for appropriate corrective action.
Closure Date:
2 The Under Secretary for Health implements a clearly defined decision matrix that allows staff to accurately determine when claims should be denied, rejected, or approved; initiate a process to systematically audit denied and rejected claims; and take corrective actions as needed based on audit results.
Closure Date:
3 The Under Secretary for Health develops and implements a control to ensure claims processors have the appropriate options in the claims-processing system of record to request evidence necessary to substantiate third-party liability claims.
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4 The Under Secretary for Health reevaluates all sample claims identified in this audit as inappropriately denied and rejected for appropriate corrective action.
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5 The Under Secretary for Health reevaluates production targets, work production credits, and application of non processing time for voucher examiners to ensure the production targets include claims research.
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6 The Under Secretary for Health requests and ensures the Office of Resolution Management conducts an organizational assessment of the Claims Adjudication and Reimbursement processing locations where staff reported they were directed or encouraged to improperly process claims, and to take appropriate action.
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7 The Under Secretary for Health implements strategic plans to ensure the Office of Community Care, Claims Adjudication and Reimbursement Directorate, emphasizes the accuracy of claims-processing decisions.
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8 The Under Secretary for Health implements controls to ensure eligibility for overtime, telework, and annual performance bonuses for Claims Adjudication and Reimbursement staff includes all facets of performance.
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9 The Under Secretary for Health develops and implements a clearly defined and effective quality assurance program that encompasses all claims decisions and includes a standardized process for supervisors to determine and effectively monitor the extent to which claims processors accurately rejected and denied non VA emergency care claims.
Closure Date:
10 The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities routinely communicate backlogs of incoming mail to Office of Community Care leaders with associated action plans to accurately record the date the documents were received.
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11 The Under Secretary for Health develops and implements clearly defined controls to ensure Claims Adjudication and Reimbursement processing facilities and VA medical centers timely communicate claims decisions to veterans and providers to ensure veterans are notified of what VA needs to adjudicate the claims and what actions the veteran may take in response.
Closure Date:
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| 17-03557-177 | Episodes of Non-Adherence to Privacy and Security Policies at the Tibor Rubin VA Medical Center, Long Beach, California | Hotline Healthcare Inspection | ||
1 The Tibor Rubin VA Medical Center Director reviews the communication processes between employees and Biomedical Engineering and Information Technology departments regarding disclosure of patient sensitive information when interface issues exist and takes necessary actions to improve this communication.
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2 The Tibor Rubin VA Medical Center Director ensures that facility healthcare staff can identify which patient information or combination of patient information is considered protected from disclosure and staff transfers protected information across all communication modes, including emails and text pages, according to VA/Veterans Health Administration policy.
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3 The Tibor Rubin VA Medical Center Director ensures that the Privacy Officer and the Information Systems Security Officer take necessary steps when protected patient information is compromised or possibly breached.
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4 The Tibor Rubin VA Medical Center Director considers offering credit monitoring to the 133 identified patients.
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5 The VA Assistant Secretary for Information and Technology reviews and adjusts the Veterans Administration Handbook 6500.2, Management of Breaches Involving Sensitive Personal Information, to include a process and guidance to address sensitive personal information incidents and events such as the use of personal email systems to transfer and store patient sensitive information and texting with personal cell phones.
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6 The Tibor Rubin VA Medical Center Director reviews the facility’s policy and use of physical logbooks and ensures compliance with Veterans Health Administration policy.
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| 18-03390-178 | Follow-Up Review of the Veterans Crisis Line, Canandaigua, New York; Atlanta, Georgia; and Topeka, Kansas | Hotline Healthcare Inspection | ||
1 The Veterans Crisis Line director ensures analysis of rescue efforts ending because the caller’s location cannot be found, identifies and analyzes metrics that may have contributed to the inability to locate these rescues, and takes remedial action.
Closure Date:
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| 19-06386-179 | Factors Contributing to the Death of a Ventilator-Dependent Patient at the VA San Diego Healthcare System, California | Hotline Healthcare Inspection | ||
1 The VA San Diego Healthcare System Director ensures that a policy is developed, staff is trained, and compliance is monitored related to the use of the Passy-Muir® Valve on the Spinal Cord Injury unit to include:
a) Staff education on ventilator alarm settings when an in-line Passy-Muir® Valve is used,
b) Documentation and monitoring of ventilator settings before, during, and after Passy-Muir® Valve use,
c) Documentation of length of time the Passy-Muir® Valve is in place,
d) Back-up plan for monitoring patients on a Passy-Muir® Valve,
e) Patient supervision while using the Passy-Muir® Valve, and
f) Patient and family education on the safe use of the Passy-Muir® Valve.
Closure Date:
2 The VA San Diego Healthcare System Director ensures that a policy is developed for the use of ventilator anti-disconnect devices, that staff are trained, and that compliance is monitored.
Closure Date:
3 The VA San Diego Healthcare System Director confers with the National Center for Patient Safety to determine if a National Patient Safety Advisory should be issued regarding a potential deficit in training for staff who care for ventilated patients in non-intensive care unit settings.
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4 The VA San Diego Healthcare System Director ensures that Spinal Cord Injury and respiratory therapy staff are provided refresher training regarding issues to report to the Patient Safety program.
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5 The VA San Diego Healthcare System Director ensures that Spinal Cord Injury leadership reviews clinical alarms annually and ensures that the review is discussed and documented in Spinal Cord Injury Leadership Committee minutes.
Closure Date:
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| 18-05731-176 | Concerns Related to an Inpatient’s Response to Oxycodone and Facility Actions at the Baltimore VA Medical Center, Maryland | Hotline Healthcare Inspection | ||
1 The VA Maryland Health Care System director takes steps to ensure resident supervision meets requirements, and monitors for compliance with Veterans Health Administration policy.
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2 The VA Maryland Health Care System director verifies the capture and reporting of adverse drug events to the national Veterans Health Administration Adverse Drug Event Reporting System, and monitors for compliance.
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3 The VA Maryland Health Care System director ensures staff complete root cause analyses or aggregated reviews for adverse events as required by Veterans Health Administration policy and monitors to ensure completion.
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4 The VA Maryland Health Care System director verifies documentation of clinical disclosures when perceptible effects of an adverse event have occurred, as required, and monitors for compliance.
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5 The VA Maryland Health Care System director ensures peer reviews are evaluated according to VA Maryland Health Care System policy and monitors for compliance.
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6 The VA Maryland Health Care System director verifies that the Surgical Work Group meets and documents minutes as required to include improvement data presentation, discussion, and performance tracking, and monitors for compliance.
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| 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.
Closure Date:
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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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