Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 18-00693-41 | 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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| 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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| 18-01163-36 | 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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| 18-01278-13 | 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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15039