Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-01146-35 | Comprehensive Healthcare Inspection Program Review of the Durham VA Medical Center, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Executive Council of Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion to recommend approval of clinical privileges for LIPs and monitors compliance.
Closure Date:
2 The Facility Director ensures Controlled Substances Inspectors complete monthly pharmacy prescription pad inventories and monitors compliance.
Closure Date:
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| 18-01278-13 | Delays in the Processing of Survivors' and Dependents' Educational Assistance Program Benefits Led to Duplicate Payments | Audit | ||
1 The OIG recommended the Under Secretary for Benefits direct Compensation Service and Office of Field Operations to develop and implement processes and procedures that ensure monitoring of Survivors’ and Dependents’ Educational Assistance electronic mailboxes and timely establishment of compensation adjustments.
Closure Date:
2 The OIG recommended the Under Secretary for Benefits direct Education Service to develop and implement an effective process to ensure receipt of Survivors’ and Dependents’ Educational Assistance benefit notifications by VA Regional Office staff.
Closure Date:
3 The OIG recommended the Under Secretary for Benefits ensure Compensation Service and Education Service develop electronic system functionality to identify cases with potential duplication of benefits when a dependent begins receiving Survivors’ and Dependents’ Educational Assistance payments.
Closure Date:
4 The OIG recommended the Under Secretary for Benefits ensure the National Work Queue and Compensation Service assign cases with compensation adjustments to remove the school child allowance as soon as the cases are ready for processing.
Closure Date:
5 The OIG recommended the Under Secretary for Benefits ensure Office of Field Operations takes prompt action to adjust benefits for cases in the OIG sample in which payment duplications had not been identified.
Closure Date:
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| 18-01157-31 | Comprehensive Healthcare Inspection Program Review of the Iowa City VA Health Care System, Iowa | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs complete all required elements, including specialty-specific criteria, for Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
2 The Facility Director ensures that controlled substances program staff complete reconciliation of controlled substances returns to pharmacy stock during controlled substance inspections and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that geriatric evaluation program performance improvement activities are conducted and reviewed by an appropriate leadership board or council and monitors compliance.
Closure Date:
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| 18-01159-38 | Comprehensive Healthcare Inspection Program Review of the West Palm Beach VA Medical Center, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers consistently implement and document actions recommended by the Peer Review Committee and monitors compliance.
Closure Date:
2 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:
3 The Director ensures implementation of root cause analysis actions and feedback of results to the reporting individuals or departments and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that service chiefs complete required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors compliance.
Closure Date:
5 The Chief of Staff ensures the service chiefs include service-specific criteria in Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
6 The Associate Director ensures all staff are educated on how to access safety data sheet information and monitors compliance.
Closure Date:
7 The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
8 The Associate Director ensures the Port Saint Lucie Community Based Outpatient Clinic panic alarms are functional and regularly tested and monitors compliance.
Closure Date:
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| 18-01161-28 | Comprehensive Healthcare Inspection Program Review of the Salem VA Medical Center, Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that Facility managers develop and implement a comprehensive Facility policy on the use and care of central lines and monitor compliance.
Closure Date:
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| 18-01154-27 | Comprehensive Healthcare Inspection Program Review of the VA Pittsburgh Healthcare System, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that the Medical Executive Board uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
Closure Date:
2 The Chief of Staff ensures service chiefs complete all required elements, including minimum required specialty criteria for Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
3 The Deputy Director ensures that a safe and clean environment is maintained throughout the Facility and Westmoreland County Community Based Outpatient Clinic and monitors compliance.
Closure Date:
4 The Deputy Director ensures the flooring in the mental health seclusion rooms provides cushioning.
Closure Date:
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| 17-01007-01 | Inadequate Governance of the VA Police Program at Medical Facilities | Audit | ||
1 Clarify program responsibilities between the Veterans Health Administration and theOffice of Operations, Security, and Preparedness, and evaluate the need for a centralizedmanagement entity for the security and law enforcement program across all medicalfacilities.
2 Ensure police staffing models are implemented for determining facility-appropriate levelsfor officers at medical facilities.
Closure Date:
3 Make certain medical facilities use strategies to address police staffing challenges such ashaving documented recruitment plans for police officer positions that include adetermination of the need for special salary rates and incentives.
Closure Date:
4 Assess the staffing levels for the Office of Security and Law Enforcement policeinspection program, and authorize and provide sufficient resources to conduct timelyinspections of police units at medical facilities to help identify program complianceissues.
Closure Date:
5 Ensure procedures are developed for appropriately handling VA police investigations of medical facility leaders.
Closure Date:
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| 17-02163-23 | Provider Assignment and Dermatology Consult Scheduling Delays at the Joint Ambulatory Care Center, Pensacola, Florida | Hotline Healthcare Inspection | ||
1 The Gulf Coast Veterans Health Care System Director ensures that patients are assigned primary care providers, as required by Veterans Health Administration policy, and that the assignments are monitored for compliance.
Closure Date:
2 The Gulf Coast Veterans Health System Director ensures that patients with Joint Ambulatory Care Center dermatology consults are scheduled as required by Veterans Health Administration policy and within the Veterans Health Administration consult timeframe, and that the scheduling process is monitored for compliance.
Closure Date:
3 The Gulf Coast Veterans Health Care System Director ensures that system managers review dermatology and non-VA care scheduling staffing levels, and develop an action plan to address recommendations, if any, from the staffing level reviews.
Closure Date:
4 The Gulf Coast Veterans Health System Director takes appropriate action as related to Patient B’s physicians’ improper electronic health record documentation as discussed in this report.
Closure Date:
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| 18-01142-25 | Comprehensive Healthcare Inspection Program Review of the G.V. (Sonny) Montgomery VA Medical Center, Jackson, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that service chiefs communicate to the Peer Review Committee the completion of individual improvement actions and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that all Focused Professional Practice Evaluations include clearly delineated timeframes and monitor compliance.
Closure Date:
3 The Chief of Staff ensures that clinical managers consistently collect and maintain Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
4 The Associate Director ensures that staff store clean and dirty equipment separately and monitors compliance.
Closure Date:
5 The Associate Director ensures the mental health unit seclusion room toilet is shatterproof.
Closure Date:
6 The Associate Director ensures that environment of care rounds are conducted as required at the McComb Community Based Outpatient Clinic and monitors compliance.
Closure Date:
7 The Associate Director ensures that staff at the McComb Community Based Outpatient Clinic remove all expired, damaged, and/or contaminated medications and monitors compliance.
Closure Date:
8 The Associate Director ensures the McComb Community Based Outpatient Clinic managers maintain a safe and clean environment and monitors compliance.
Closure Date:
9 The Associate Director ensures that shelving is clean and bottom storage shelves are solid at the McComb Community Based Outpatient Clinic and monitors compliance.
Closure Date:
10 The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive posttraumatic stress disorder screens and monitors compliance.
Closure Date:
11 The Chief of Staff ensures that acceptable providers offer and refer patients with positive posttraumatic stress disorder screens for further diagnostic evaluations and monitors compliance.
Closure Date:
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| 18-01144-24 | Comprehensive Healthcare Inspection Program Review of the Mann-Grandstaff VA Medical Center, Spokane, Washington | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from social work and the Chief Business Office revenue utilization review and monitors compliance.
Closure Date:
2 The Chief of Staff ensures Ongoing Professional Practice Evaluations utilize assessments by providers with similar training and privileges and monitors compliance.
Closure Date:
3 The Associate Director ensures managers clearly mark and securely store medical biohazardous waste and monitors compliance.
Closure Date:
4 The Associate Director ensures the Police and Security Operations document response time to panic alarm testing at the locked mental health unit and monitors compliance.
Closure Date:
5 The Associate Director ensures that the Emergency Management Plan is reviewed annually and monitors compliance.
Closure Date:
6 The Facility Director ensures that the Quality Council maintains oversight of all geriatric evaluation program performance improvement activities and monitors compliance.
Closure Date:
7 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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14957