Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 18-01145-26 | Comprehensive Healthcare Inspection Program Review of the VA Southern Nevada Healthcare System, North Las Vegas, Nevada | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
Closure Date:
2 The Associate Director ensures the VA Police regularly test panic alarms at the Northwest Las Vegas VA Clinic and monitors compliance.
Closure Date:
3 The Associate Director ensures the VA Police test panic alarms and document response time to alarm testing in the locked mental health unit and monitors compliance.
Closure Date:
4 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are addressed and monitors compliance.
Closure Date:
5 The Facility Director ensures controlled substance monthly inspection dates are randomly selected to avoid distinguishable patterns and monitors compliance.
Closure Date:
6 The Facility Director ensures that controlled substances inspectors perform reconciliation of controlled substance refills to automated dispensing cabinets in patient care areas and returns to pharmacy stock and monitors compliance.
Closure Date:
7 The Facility Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and monitors compliance.
Closure Date:
8 The Facility Director ensures that Geriatrics and Extended Care Service leaders conduct and report geriatric evaluation program performance improvement activities to an appropriate leadership board and monitors compliance.
Closure Date:
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| 16-00862-179 | VA’s Oversight of State Approving Agency Program Monitoring for Post-9/11 GI Bill Students | Audit | ||
1 The Under Secretary for Benefits negotiates an amendment to State Approving Agency contracts to clarify requirements for program approvals and require, subject to the availability of resources, quarterly samples and reviews and evaluations of supporting documentation for State Approving Agency approvals to ensure approved programs meet Title 38 of the United States Code requirements.
Closure Date:
2 The Under Secretary for Benefits negotiates amendments to State Approving Agency contracts that, subject to available resources, require the State Approving Agencies to periodically reapprove programs and evaluate program changes and other operational changes, such as advertisement practices, that may affect a program’s continued eligibility and compliance with Title 38 of the United States Code.
Closure Date:
3 The Under Secretary for Benefits refers schools identified during the audit with potentially erroneous, deceptive, or misleading advertising practices to the Federal Trade Commission for it to decide whether any further reviews or actions are needed.
Closure Date:
4 The Under Secretary for Benefits revises and strengthens compliance surveys to improve the assessment of program eligibility and compliance survey quality reviews to include the review of supporting documentation and an independent assessment of the quality of the completed compliance surveys.
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5 The Under Secretary for Benefits negotiates an amendment to the State Approving Agency contracts to establish quality assurance metrics and ensure the Veterans Benefits Administration collects and uses quality assurance data from its reviews of the State Approving Agencies’ approvals, monitoring, and compliance surveys in its annual evaluations of the State Approving Agencies.
Closure Date:
6 The Under Secretary for Benefits assesses whether funding for State Approving Agencies is sufficient to ensure the adequate review, approval, and monitoring of programs, in conjunction with the establishment of a contract to update the State Approving Agency funding allocation model.
Closure Date:
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| 18-01137-15 | Comprehensive Healthcare Inspection Program Review of the Central Texas Veterans Health Care System, Temple, Texas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Service Chiefs include clearly delineated timeframes in practitioners’ Focused Professional Practice Evaluation competency reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures Service Chiefs present the results of completed Focused Professional Practice Evaluations to the Medical Staff Executive Council to recommend continuing the initially granted privileges and monitors compliance.
Closure Date:
3 The Chief of Staff ensures Service Chiefs include service-specific data in Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that the Chief, Pathology and Laboratory Medicine Service, includes the required pathology-specific criteria, as applicable, in pathology practitioners’ Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
5 The Associate Director ensures personal protective equipment is readily accessible and monitors compliance.
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6 The Assistant Director–Waco ensures that a clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
7 The Associate Director and Assistant Director–Austin ensure that prescribed sleep apnea equipment is furnished timely to patients and monitor compliance.
Closure Date:
8 The Associate Director ensures VA Police and Security Service regularly test panic alarms and take follow-up actions for identified deficiencies at the Austin Community Based Outpatient Clinic and monitors compliance.
Closure Date:
9 The Associate Director ensures VA Police and Security Service regularly test panic alarms and take follow-up actions for identified deficiencies at the Waco campus locked mental health unit and monitors compliance.
Closure Date:
10 The Assistant Director–Waco ensures that the Emergency Operations Plan is reviewed annually by the Emergency Management Committee and approved by executive leadership and monitors compliance.
Closure Date:
11 The Facility Director ensures that the Controlled Substance Coordinator completes monthly summary of findings and quarterly trend reports and monitors compliance.
Closure Date:
12 The Facility Director ensures that Controlled Substances Inspectors are appointed in writing prior to performing inspector duties and monitors compliance.
Closure Date:
13 The Facility Director ensures that Controlled Substances Inspectors complete routine monthly controlled substances inspections and monitors compliance.
Closure Date:
14 The Facility Director ensures that Controlled Substances Inspectors verify drugs held for destruction during monthly inspections at the Waco inpatient pharmacy and monitors compliance.
Closure Date:
15 The Facility Director ensures Controlled Substances Inspectors complete pharmacy prescription pad inventories during monthly pharmacy inspections at the Waco outpatient pharmacy and monitors compliance.
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16 The Facility Director ensures that Controlled Substances Inspectors verify evidence of written prescriptions for non-electronic controlled substance orders during monthly area inspections at the Temple outpatient pharmacy and monitors compliance.
Closure Date:
17 The Chief of Staff ensures providers or designees communicate mammogram results to patients and monitors compliance.
Closure Date:
18 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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| 18-01152-14 | Comprehensive Healthcare Inspection Program Review of the VA Maine Healthcare System, Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures the Patient Safety Manager or designee provides feedback about root cause analysis actions to the reporting individuals or departments and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that the Clinical Executive Board reviews and evaluates licensed independent practitioners’ initial and re-privileging requests prior to making recommendations to the Facility Director and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that clinical managers complete all required elements for Focused Professional Practice Evaluations for the determination of practitioners’ privileges and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
5 The Associate Director ensures all staff are educated on how to access safety data sheet information and monitors compliance.
Closure Date:
6 The Facility Director ensures that Controlled Substance Inspectors conduct monthly controlled substance inspections and monitors compliance.
Closure Date:
7 The Associate Director ensures that geriatric evaluation performance improvement activities are reviewed by a Facility leadership board and monitors compliance.
Closure Date:
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| 18-02210-19 | Patient and Radiation Safety Concerns at the John D. Dingell VA Medical Center, Detroit, Michigan | Hotline Healthcare Inspection | ||
1 The John D. Dingell VA Medical Center Director ensures that radiologic equipment receives the required inspection and testing by a qualified medical physicist, and monitors compliance.
Closure Date:
2 The John D. Dingell VA Medical Center Director ensures providers and radiology technicians complete fluoroscopy training as required, and monitors for compliance.
Closure Date:
3 The John D. Dingell VA Medical Center Director ensures clinical privileges are granted in accordance with policy, and monitors for compliance.
Closure Date:
4 The John D. Dingell VA Medical Center Director ensures that the radiology department conform to radiation safety standards as outlined through the National Health Physics Program and fully address any recommendations and violations, and monitors to completion.
Closure Date:
5 The John D. Dingell VA Medical Center Director ensures that the Radiation Safety Committee minutes reflect actions taken to address National Health Physics Program recommendations and violations, and monitors compliance.
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6 The John D. Dingell VA Medical Center Director ensures that the Radiation Safety Officer and Radiation Safety Committee initiate and utilize the Veterans Health Administration required tracking matrix to track unresolved action items to completion, and monitors compliance.
Closure Date:
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| 18-00031-05 | Accuracy of Claims Involving Service-Connected Amyotrophic Lateral Sclerosis | Audit | ||
1 The Under Secretary for Benefits implements a plan to improve the decisions and additional reviews of claims involving service-connected Amyotrophic Lateral Sclerosis, and monitors these claims to ensure staff demonstrate proficiency.
Closure Date:
2 The Under Secretary for Benefits implements a plan to ensure veterans with service-connected Amyotrophic Lateral Sclerosis receive notice regarding additional special monthly compensation benefits that may be available.
Closure Date:
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| 17-04127-266 | Alleged Misuse of Government-Owned Vehicles at the Sacramento VA Medical Center, California | Investigative | ||
1 The VA Sierra Pacific Network Director confers with the Offices of General Counsel,Human Resources, and Accountability and Whistleblower Protection to determine theappropriate administrative action to take, if any, against Dr. Erckenbrack.
Closure Date:
2 The VA Sierra Pacific Network Director confers with the Offices of General Counsel,Human Resources, and Accountability and Whistleblower Protection to determine theappropriate administrative action to take, if any, against the Chief of LogisticsManagement Service.
Closure Date:
3 The VA Sierra Pacific Network Director confers with the Office of General Counsel andthe Director of the VA Northern California Health Care System to ensure that controlsare in place to oversee proper implementation by the Health Care System of federal law,regulations, and VA policy regarding the use of government-owned vehicles.
Closure Date:
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| 18-01496-301 | Emergency Cache Program: Ineffective Management Impairs Mission Readiness | Audit | ||
1 The Executive in Charge, Veterans Health Administration, should develop requirements for medical facilities with emergency caches to perform at least annually a wall-to-wall inventory of all cache drugs and supplies, and develop processes to (1) label all expired or excess drugs that are purposefully maintained to respond to drug shortages or for the purposes of Shelf Life Extension testing, and (2) remove and rectify cases of other expired, missing, or excess drugs.
Closure Date:
2 The Executive in Charge, Veterans Health Administration, should conduct an assessment to determine if the cost saving benefits of the Shelf Life Extension Program outweigh the risks expired drugs pose to the emergency cache’s mission and to take corrective action as appropriate.
Closure Date:
3 The Executive in Charge, Veterans Health Administration, should improve emergency cache inventory management processes to ensure emergency cache national inventory data sorted by location is reliable and accurately identifies the expiration dates of all cache contents, including Shelf Life Extension Program drugs, and that this information is electronically accessible to each facility.
Closure Date:
4 The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program with a requirement for inventory to be timely rotated into the emergency cache after it is received.
Closure Date:
5 The Executive in Charge, Veterans Health Administration, should assess whether the Emergency Cache Program is properly aligned within VA and coordinate with other VA offices as necessary to determine the appropriate roles and responsibilities by program office, and then review, update, and reissue Emergency Cache Program requirements to include (1) robust annual cache inspection and activation exercise requirements, (2) processes to ensure cache inspection and activation requirements are met, (3) processes to ensure that violations identified during annual cache inspections are timely addressed, and (4) specific accountability measures for the program offices and local facility personnel responsible for program oversight.
Closure Date:
6 The Executive in Charge, Veterans Health Administration, should conduct a comprehensive assessment of the cache inventory to identify drugs and supplies that can be readily used in medical facilities’ general operations and develop a mechanism to monitor and ensure medical facilities are maximizing the use of these items before they expire.
Closure Date:
7 The Executive in Charge, Veterans Health Administration, should initiate steps to update and reissue the Veterans Health Administration directives specifying oversight responsibilities for the Emergency Cache Program to reflect the Office of Public Health’s reorganization and reassign responsibilities as needed.
Closure Date:
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| 17-04593-10 | Alleged Concerns in Sterile Processing Services 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 Sterile Processing Services staff adhere to the missing instrument procedures for sterile sets as required by Veterans Health Administration policy.
Closure Date:
2 The New Mexico VA Health Care System Director ensures that Sterile Processing Services staff adhere to the requirements for verification of items in sterile sets as required by Veterans Health Administration policy.
Closure Date:
3 The New Mexico VA Health Care System Director evaluates patient safety reporting systems to ensure that all events are captured in WebSPOT as required by Veterans Health Administration policy.
Closure Date:
4 The New Mexico VA Health Care System Director ensures that all Sterile Processing Services staff, including contract staff, complete training as required by Veterans Health Administration Directive 1116 (2).
Closure Date:
5 The New Mexico VA Health Care System Director verifies that Sterile Processing Services managers maintain an accurate list for reusable medical equipment and copies of manufacturers’ instructions as required by Veterans Health Administration policy and the April 2017 Deputy Under Secretary for Health for Operations and Management memorandum.
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6 The New Mexico VA Health Care System Director ensures that Sterile Processing Services maintain updated and readily accessible standard operating procedures for all instruments and equipment within Sterile Processing Services in accordance with Veterans Health Administration policy.
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7 The New Mexico VA Health Care System Director ensures that competency assessments for all Sterile Processing Services staff, including contract staff, are conducted and documented as required by Veterans Health Administration Directive 1116 (2).
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8 The New Mexico VA Health Care System Director reviews the contract related to Sterile Processing Services technicians to determine if requirements for training and certification are consistent with Veterans Health Administration Directive 1116 (2) and takes action as necessary.
Closure Date:
9 The Veterans Integrated Service Network 22 Director ensures that the New Mexico VA Health Care System Director implements action items from previous external Sterile Processing Services inspection reviews.
Closure Date:
10 The Veterans Integrated Service Network 22 Director oversees implementation of this report’s recommendations that are directed to the New Mexico VA Health Care System Director.
Closure Date:
11 The Veterans Integrated Service Network 22 Director reviews the New Mexico VA Health Care System’s Sterile Processing Services risk assessment to determine if identified high-risk items and areas are in alignment with guidance from the Deputy Under Secretary for Health for Operations and Management and takes action as necessary.
Closure Date:
12 The Veterans Integrated Service Network 22 implements a process that identifies instances when independent verification by Veterans Integrated Service Network staff is necessary to ensure that the Facility implements action plans related to Sterile Processing Services recommendations.
Closure Date:
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| 18-01136-313 | Comprehensive Healthcare Inspection Program Review of the Louis A. Johnson VA Medical Center, Clarksburg, West Virginia | 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 Facility Director ensures the interdisciplinary group or committee that reviews utilization management data includes required representatives and meets regularly and monitors compliance.
Closure Date:
3 The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
4 The Chief of Staff ensures the Medical Executive Council uses and documents the use of the results of Ongoing Professional Practice Evaluations in the determination of whether to recommend continuation of licensed independent practitioners’ privileges and monitors compliance.
Closure Date:
5 The Associate Director ensures that damaged furniture is repaired or removed from service and monitors compliance.
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6 The Associate Director ensures weekly inspections of the emergency power supply system are performed and documented and monitors compliance.
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7 The Facility Director ensures that controlled substance inspectors perform reconciliation of controlled substance dispensing from the pharmacy to automated dispensing cabinets and returns to pharmacy stock during monthly area inspections and monitors compliance.
Closure Date:
8 The Facility Director ensures that controlled substance inspectors verify controlled substance orders during monthly area inspections and monitors compliance.
Closure Date:
9 The Associate Director for Patient Care Services ensures that all staff involved in inserting and managing central lines receive the required central line-associated bloodstream infection and infection prevention education and monitors compliance.
Closure Date:
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14957