Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01757-50 | Comprehensive Healthcare Inspection Program Review of the Washington DC VA Medical Center | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that recommended actions from peer reviews and root cause analyses are implemented and monitored for improvement.
Closure Date:
2 The Chief of Staff ensures that assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors the staff’s compliance.
Closure Date:
3 The Chief of Staff ensures an interdisciplinary Facility group reviews utilization management data and monitors the group’s compliance.
Closure Date:
4 The Facility Director ensures that the Patient Safety Manager provides feedback of root cause analysis results to the reporting individuals or departments and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that Focused and Ongoing Professional Practice Evaluations are completed, and that the Professional Standards Board reviews these evaluations in considering whether to continue provider privileges, and monitors compliance.
Closure Date:
6 The Associate Director ensures that safety and infection prevention processes are in place at construction sites and monitors compliance.
Closure Date:
7 The Associate Director for Patient Care Services ensures that nursing staff dispose of expired or unsealed supplies and monitors the staff’s compliance.
Closure Date:
8 The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
9 The Associate Director ensures all applicable equipment is inspected and identified as safe for patient use and monitors compliance.
Closure Date:
10 The Associate Director ensures the mental health seclusion room flooring provides cushioning.
Closure Date:
11 The Associate Director ensures the furniture in the mental health seclusion room is limited to an appropriate style bed and monitors for compliance.
Closure Date:
12 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are addressed or corrected and monitors compliance.
Closure Date:
13 The Facility Director ensures that electronic access for performing or monitoring controlled substance balance adjustments is limited to appropriate staff and monitors compliance.
Closure Date:
14 The Facility Director ensures that the duties of the Controlled Substance Coordinator and Alternate Controlled Substance Coordinator are included in the employees’ position description or functional statement.
Closure Date:
15 The Facility Director ensures that a reconciliation of controlled substance return to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Closure Date:
16 The Chief of Staff ensures that the geriatric evaluation performance improvement activities are reviewed by the appropriate leadership board and monitors compliance.
Closure Date:
17 The Associate Director for Patient Care Services ensures that all registered nurses involved in the insertion and/or management of central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors compliance.
Closure Date:
18 The Facility Director ensures the Chief of Health Information Management facilitate the timely scanning of clinical reports into the electronic health record and monitors compliance.
Closure Date:
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| 18-05264-58 | Alleged Clinical and Administrative Concerns Involving a Wound Care Provider in Veterans Integrated Service Network 21 | Hotline Healthcare Inspection | ||
1 The System Director ensures completion of evaluations of Patients B and C to determine whether opportunities for more timely diagnosis of deep vein thrombosis existed, and takes action if indicated.
Closure Date:
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| 17-03499-20 | Mismanagement of the VA Executive Protection Division | Audit | ||
1 The Acting Assistant Secretary for Human Resources and Administration ensures that the VA Police Service publishes written operational policies and procedures designed to regulate essential functions of the Executive Protection Division, including threat assessment processes, motorcade operations, security drills, equipment maintenance, use of personal protective gear, and other topics deemed appropriate after consultation with executive protection experts.
Closure Date:
2 The Acting Assistant Secretary for Human Resources and Administration makes certain that an adequate threat assessment is developed and kept current for each principal secured by the Executive Protection Division.
Closure Date:
3 The Acting Assistant Secretary for Human Resources and Administration, along with the Director of the Office of Security and Law Enforcement and the Director of Police Service, reviews the U.S. Secret Service recommendation made to VA in April 2017 about shift scheduling and either implements the recommendation or thoroughly documents the reasons for non-implementation.
Closure Date:
4 The Acting Assistant Secretary for Human Resources and Administration confers with the VA Offices of General Counsel and Accountability and Whistleblower Protection to ensure that bills of collection are issued to agents identified as receiving improper payments of overtime or travel reimbursement and to determine the appropriate administrative action to take, if any, against agents and supervisors who submitted or approved falsified time cards.
Closure Date:
5 The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to determine the appropriate administrative action to take, if any, against personnel involved with the nonsecure transmission of the former VA Secretary’s anticipated movements to individuals external to VA who had no need to know.
Closure Date:
6 The Acting Assistant Secretary for Human Resources and Administration ensures that the Executive Protection Division institutes procedures to report and appropriately address security lapses, such as those described in this report, and holds agents accountable for individual conduct that contributes to such lapses.
Closure Date:
7 The Acting Assistant Secretary for Human Resources and Administration establishes written procedures for documenting the review and approval of employee overtime within the Executive Protection Division and ensures compliance.
Closure Date:
8 The Acting Assistant Secretary for Human Resources and Administration assesses and takes remedial action, if necessary, to make certain that Executive Protection Division staff use parking and transit benefits in accordance with VA policy.
Closure Date:
9 The Acting Assistant Secretary for Human Resources and Administration confers with the Offices of General Counsel and Accountability and Whistleblower Protection to determine whether any agents inappropriately accepted transit benefits while using VA parking spaces, and if so, determine the appropriate administrative action to take, if any.
Closure Date:
10 The Acting Assistant Secretary for Human Resources and Administration works with the Offices of General Counsel and Accountability and Whistleblower Protection to institute procedures for an ombudsman or similar function that will enable the Executive Protection Division agents to address management disputes without needing to involve the VA Secretary.
Closure Date:
11 The Acting Assistant Secretary for Human Resources and Administration consults with the Office of General Counsel to confirm that the Executive Protection Division and the Office of Secretary have written policies and procedures reasonably designed to ensure that the principal under protection receives a thorough orientation to the appropriate uses of the Division’s services.
Closure Date:
12 The Acting Assistant Secretary for Human Resources and Administration consults with the Offices of General Counsel and Accountability and Whistleblower Protection to provide adequate mechanisms and training for all staff within the Office of Operations, Security, and Preparedness, including the Executive Protection Division, that ensure allegations of perceived misconduct by the VA Secretary can be appropriately addressed without the threat of retaliation.
Closure Date:
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| 18-02056-54 | Concerns Related to the Management of a Patient’s Medication at Three VA Medical Centers and Inaccurate Response to a Congressional Inquiry at the VA Illiana Health Care System, Danville, Illinois | Hotline Healthcare Inspection | ||
1 The Orlando VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
Closure Date:
2 The Orlando VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of electrocardiogram test results and follow-up as clinically indicated.
Closure Date:
3 The Richard L. Roudebush VA Medical Center Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
Closure Date:
4 The Richard L. Roudebush VA Medical Center Director verifies staff compliance with Veterans Health Administration policies related to patient notification of medication blood level test results and follow-up as clinically indicated.
Closure Date:
5 The VA Illiana Health Care System Director evaluates the care of the subject patient with respect to the patient’s cardiac complaints and takes action, as appropriate, including clinical disclosure.
Closure Date:
6 The VA Illiana Health Care System Director strengthens processes for effective clinical consultation and follow-up between mental health and collaborating primary care providers.
Closure Date:
7 The VA Illiana Health Care System Director strengthens the processes for congressional inquiry response to ensure response timeliness, clinical information accuracy, and records retention, as required.
Closure Date:
8 The VA Illiana Health Care System Director evaluates staff actions and approval processes in the preparation of the letter to Senator Donnelly, and takes appropriate administrative action, if indicated.
Closure Date:
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| 18-01155-48 | Comprehensive Healthcare Inspection Program Review of the Marion VA Medical Center, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs collect Ongoing Professional Practice Evaluation data utilizing assessments by providers with similar training and privileges and monitors compliance.
Closure Date:
2 The Associate Director ensures Police Service regularly tests panic alarm testing and addresses identified deficiencies at the Harrisburg Community Based Outpatient Clinic and monitors compliance.
Closure Date:
3 The Associate Director ensures that the Emergency Operations Plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
Closure Date:
4 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
5 The Facility Director ensures controlled substances inspectors verify a corresponding sealed evidence bag containing drug(s) for each medication held for destruction at the Evansville Health Care Center and monitors compliance.
Closure Date:
6 The Associate Director for Patient Care Services ensures that all registered nurses involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
Closure Date:
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| 18-01164-42 | Comprehensive Healthcare Inspection Program Review of the VA New Jersey Health Care System, East Orange, New Jersey | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers initiate and document Focused Professional Practice Evaluations that include provider- and service-specific criteria for the determination of providers’ privileges and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that Ongoing Professional Practice Evaluations include service-specific criteria and are completed by a provider with similar training and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that the Executive Committee of the Medical Staff reviews Ongoing Professional Practice Evaluations in the consideration to grant provider privileges and monitors compliance.
Closure Date:
4 The Associate Director–Lyons Campus ensures that managers store clean and dirty medical equipment separately and monitors compliance.
Closure Date:
5 The Associate Director–Lyons Campus ensures that Public Safety Service documents the response times when testing panic alarms and monitors compliance.
Closure Date:
6 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
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| 18-01153-43 | Comprehensive Healthcare Inspection Program Review of the San Francisco VA Health Care System, California | 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 compliance.
Closure Date:
2 The Chief of Staff ensures an interdisciplinary Facility group reviews utilization management data and monitors compliance.
Closure Date:
3 The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations and monitors compliance.
Closure Date:
4 The Chief of Staff ensures service chiefs present the results of completed Focused Professional Practice Evaluations to the Medical Executive Committee to recommend continuing the initially granted privileges and monitors compliance.
Closure Date:
5 The Associate Director ensures that Facility managers maintain a clean and safe environment throughout the Facility and monitors compliance.
Closure Date:
6 The Associate Director ensures that all staff properly safeguard patient health information and monitors compliance.
Closure Date:
7 The Associate Director ensures the VA Police document response times to panic alarm testing in the locked mental health unit and monitors compliance.
Closure Date:
8 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.
Closure Date:
9 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Surveys are addressed and monitors compliance.
Closure Date:
10 The Facility Director ensures that controlled substances inspectors verify written or electronic controlled substance orders during monthly area inspections and monitors compliance.
Closure Date:
11 The Facility Director ensures that controlled substance inspectors complete routine monthly controlled substance inspections and monitors compliance.
Closure Date:
12 The Facility Director ensures that geriatric evaluation program performance improvement activities are conducted and reviewed by an appropriate leadership board and monitors compliance.
Closure Date:
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| 18-01147-47 | Comprehensive Healthcare Inspection Program Review of the William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
2 The Facility Director ensures that Controlled Substances Inspection program staff have no access to or involvement in drug procurement, prescribing, or dispensing, or administration of controlled substances and monitors compliance.
Closure Date:
3 The Facility Director ensures that Controlled Substances Inspectors perform reconciliation of controlled substance returns to pharmacy stock from every automated dispensing cabinet and monitors compliance.
Closure Date:
4 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 compliance.
Closure Date:
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| 18-01163-36 | Comprehensive Healthcare Inspection Program Review of the Robley Rex VA Medical Center, Louisville, Kentucky | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.
Closure Date:
2 The Facility Director ensures the Patient Safety Manager or designee provides feedback to employees or departments who submit patient safety incidents that result in root cause analysis and monitors compliance.
Closure Date:
3 The Chief of Staff ensures Focused and Ongoing Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
4 The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and Fort Knox Community Based Outpatient Clinic and monitors compliance.
Closure Date:
5 The Associate Director ensures staff assigned to conduct mental health environment of care inspections use the Mental Health Environment of Care Checklist to identify and correct deficiencies in a timely manner and monitors compliance.
Closure Date:
6 The Associate Director ensures the Facility’s Emergency Operations Plan includes required elements and that the annual review of inventory and assets is conducted and documented and monitors compliance.
Closure Date:
7 The Facility Director ensures that the Controlled Substances Coordinator’s monthly summary of findings includes all discrepancies from the inspections and monitors compliance.
Closure Date:
8 The Facility Director ensures that all deficiencies identified on the annual physical security survey are addressed and monitors compliance.
Closure Date:
9 The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Closure Date:
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| 18-00693-41 | Delay in Care and Care Coordination at Cheyenne VA Medical Center, Wyoming, and Iowa City VA Health Care System, Iowa | Hotline Healthcare Inspection | ||
1 The Cheyenne VA Medical Center Director ensures timely surveillance for cancer patients.
Closure Date:
2 The Cheyenne VA Medical Center Director improves processes for care coordination and communication between Cheyenne VA Medical Center providers and non-VA providers for cancer patients.
Closure Date:
3 The Cheyenne VA Medical Center Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.
Closure Date:
4 The Cheyenne VA Medical Center Director confers with the Office of Chief Counsel in accordance with Veterans Health Administration Handbook 1004.08 regarding institutional disclosures and takes action as necessary.
Closure Date:
5 The Cheyenne VA Medical Center Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.
Closure Date:
6 The Iowa City VA Health Care System Director ensures that processes are strengthened to ensure documentation of problem lists in accordance with Veterans Health Administration policy.
Closure Date:
7 The Iowa City VA Health Care System Director determines if peer reviews are warranted for this patient’s care and the peer reviews are performed as indicated.
Closure Date:
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14957