Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-05570-06 | Comprehensive Healthcare Inspection Program Review of the VA Boston Healthcare System, Massachusetts | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that peer reviewers consistently use at least one of the important aspects of care to evaluate peer review findings and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that Service Chiefs initiate and complete Focused Professional Practice Evaluations for newly hired licensed independent providers and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that Ongoing Professional Practice Evaluations include the review of service-specific practitioner data and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that Ongoing Professional Practice Evaluations of pathology practitioners include required pathology-specific criteria, as appropriate, and monitors compliance.
Closure Date:
5 The Deputy Director ensures that clean and dirty equipment is stored separately and monitors compliance.
Closure Date:
6 The Deputy Director ensures that bottom shelves in equipment storage areas are solid and monitors compliance.
Closure Date:
7 The Facility Director ensures that deficiencies identified on the annual physical security survey are addressed and monitors compliance.
Closure Date:
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| 18-01140-312 | Comprehensive Healthcare Inspection Program Review of the Charles George VA Medical Center, Asheville, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures the interdisciplinary group or committee that reviews utilization management data includes representatives from the Chief Business Office Revenue–Utilization Review and monitors compliance.
Closure Date:
2 The Facility Director ensures that 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 Director ensures that managers consistently implement improvement actions arising from peer review and root cause analysis activities and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that the Medical Staff Executive Council minutes consistently reflect the documents reviewed and the rationale to recommend approval of clinical privileges for license independent practitioners and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that clinical managers initiate and complete Focused and Ongoing Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that mammogram results are linked to radiology orders and monitors compliance.
Closure Date:
7 The Chief of Staff ensures that mammogram results are communicated to ordering providers and monitors compliance.
Closure Date:
8 The Chief of Staff ensures providers or designees communicate mammogram results to patients and monitors compliance.
Closure Date:
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| 18-00474-300 | VA’s Management of Land Use Under the West Los Angeles Leasing Act of 2016 | Audit | ||
1 The Principal Executive Director, Office of Acquisition, Logistics, and Construction and the Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System implement a plan that puts the West LA campus in compliance with the West Los Angeles Leasing Act of 2016, the Draft Master Plan, and other federal laws, including reasonable time periods to correct deficiencies noted in this report.
2 The Principal Executive Director, Office of Acquisition, Logistics, and Construction and the Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System ensure all non-VA entities operating on the West LA campus with expired or undocumented land use agreements establish new agreements compliant with the West Los Angeles Leasing Act.
Closure Date:
3 The Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System create a process to allow the Veterans Community Oversight and Engagement Board an opportunity to provide input to the executive leadership on West LA campus land use.
Closure Date:
4 The Principal Executive Director, Office of Acquisition, Logistics, and Construction create documented policies and procedures for out leases and Revocable Licenses to govern their use, management, and pricing to ensure fair value is received and negotiations are documented.
Closure Date:
5 The Acting Under Secretary for Health in conjunction with the Director, Greater Los Angeles Healthcare System ensure VA’s Capital Asset Inventory accurately reflects all land use agreements six months or longer on West LA campus.
Closure Date:
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| 17-05535-292 | Timeliness of Final Competency Determinations | Audit | ||
1 The Under Secretary for Benefits ensures cases requiring final competency determinations are entered into the Beneficiary Fiduciary Field System as soon as the cases are established in the Veterans Benefits Management System.
Closure Date:
2 The Under Secretary for Benefits reminds Veterans Benefits Administration staff of their responsibility to notify Fiduciary Hubs when waivers are received of the due process notification period for cases with proposed incompetency, and implements a plan to ensure compliance.
Closure Date:
3 The Under Secretary for Benefits implements a plan to ensure the processing of final competency determinations under the jurisdiction of the Fiduciary Hubs meet Veterans Benefits Administration’s established timeliness standard.
Closure Date:
4 The Under Secretary for Benefits implements a plan to prioritize the processing of final competency determinations under the jurisdiction of Veterans Service Centers and Pension Management Centers.
Closure Date:
5 The Under Secretary for Benefits ensures the National Work Queue distributes final competency determinations according to the Veterans Benefits Administration policy for processing these cases.
Closure Date:
6 The Under Secretary for Benefits implements a plan to ensure Fiduciary Hub staff who complete final competency determinations have access to documents containing federal taxpayer information in the Legacy Content Manager.
Closure Date:
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| 17-03676-307 | Quality of Care Concerns in the Hemodialysis Unit at the Wilmington VA Medical Center, Delaware | Hotline Healthcare Inspection | ||
1 The Wilmington VA Medical Center Director ensures that Hemodialysis Unit providers and staff are educated on laboratory and medication order urgency policy/processes and monitors compliance.
Closure Date:
2 The Wilmington VA Medical Center Director ensures that Facility leaders develop and implement a nursing policy that addresses verbal orders and monitors compliance.
Closure Date:
3 The Wilmington VA Medical Center Director ensures that Hemodialysis Unit providers receive training on the use of verbal orders including the use of verbal orders only in emergencies within the guidelines presented in the Facility bylaws and monitors compliance.
Closure Date:
4 The Wilmington VA Medical Center Director reviews Hemodialysis Unit staff access to and administration of medications to patients who do not have a medication order or the order has expired and takes actions as necessary.
Closure Date:
5 The Wilmington VA Medical Center Director ensures that a process is developed to notify Hemodialysis Unit staff of changes in hemodialysis orders and monitors compliance.
Closure Date:
6 The Wilmington VA Medical Center Director ensures that the Hemodialysis Unit managers adopt and provide documentation programs that will enable accuracy and efficiency in record keeping and monitors compliance.
Closure Date:
7 The Wilmington VA Medical Center Director ensures that the Code Blue members utilize the Code Blue Flow Sheet and that Rapid Response and Code Blue events are documented and presented monthly to the Facility’s Health Care Delivery Council.
Closure Date:
8 The Wilmington VA Medical Center Director ensures that the Education Department conducts unannounced mock code training twice a year in the Hemodialysis Unit with debriefings and monitors improvement and compliance.
Closure Date:
9 The Wilmington VA Medical Center Director resolves the conflict between Hemodialysis Unit staff to provide a work place environment where staff collaborates to reduce the risk of adverse patient outcomes.
Closure Date:
10 The Wilmington VA Medical Center Director evaluates the Facility’s education and training program to ensure that Safety Assessment Code assignments and Root Cause Analyses are conducted in accordance with Veterans Health Administration Handbook 1050.01, National Patient Safety Improvement.
Closure Date:
11 The Wilmington VA Medical Center Director continues efforts to recruit and hire for Hemodialysis Unit staff vacancies, and ensures that, until optimal staffing is achieved, alternate methods are consistently available to meet patient care needs.
Closure Date:
12 The Wilmington VA Medical Center Director ensures that the Chief of Medicine establishes a safe discharge process for hemodialysis patients including those who receive not routinely scheduled medications during hemodialysis and monitors compliance.
Closure Date:
13 The Wilmington VA Medical Center Director ensures Facility policies are consistent with Veterans Health Administration Handbook 1042.01, Criteria and Standards for VA Dialysis Programs, and Hemodialysis Unit providers and staff adhere to the policies.
Closure Date:
14 The Wilmington VA Medical Center Director ensures that the Facility Police Department act in alignment with VA Directive 0730 and Title 38 Code of Federal Regulations and takes actions as appropriate.
Closure Date:
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| 18-01143-302 | Comprehensive Healthcare Inspection Program Review of the Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois | Comprehensive Healthcare Inspection Program | ||
1 The Chief Medical Executive 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 all required members consistently participate in the interdisciplinary group that reviews utilization management data and monitors compliance.
Closure Date:
3 The Chief Medical Executive ensures that the Credentialing and Privileging Subcommittee consistently review Focus Professional Practice Evaluations in the granting of continued privileges and monitors compliance.
Closure Date:
4 The Associate Director for Facility Support ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
5 The Facility Director ensures that deficiencies identified on the annual physical security survey are addressed and monitors compliance.
Closure Date:
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| 18-01141-309 | Comprehensive Healthcare Inspection Program Review of the Oklahoma City VA Health Care System, Oklahoma | 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 that the Quality, Safety, and Value Committee maintains oversight of all geriatric evaluation program quality improvement activities and monitors compliance.
Closure Date:
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| 17-04875-308 | Quality of Care Concerns Regarding a Patient Who had Cardiac Surgery at the VA Ann Arbor Healthcare System, Michigan | Hotline Healthcare Inspection | ||
1 The Veterans Integrated System Network 10 Director ensures the VA Ann Arbor Healthcare System Director complies with Veterans Health Administration policies regarding requirements for root cause analysis, peer review, and institutional disclosure.
Closure Date:
2 The VA Ann Arbor Healthcare Facility Director applies quality management processes to evaluate modifications made by the anesthesiologist and surgeon for cardiothoracic surgeries and determines if modifications should be implemented system-wide.
Closure Date:
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| 18-02875-305 | Review of Mental Health Care Provided Prior to a Veteran’s Death by Suicide, Minneapolis VA Health Care System, Minnesota | Hotline Healthcare Inspection | ||
1 The Minneapolis VA Health Care System Director ensures that processes be strengthened to ensure MH interdisciplinary collaboration across levels of care in treatment planning, provision of clinical services and discharge planning, including medication management, as required by VHA.
Closure Date:
2 The Minneapolis VA Health Care System Director ensures that all MH interdisciplinary treatment team members, including the Suicide Prevention Coordinators and the outpatient care team, determine a patient’s “High Risk for Suicide” Patient Record Flag status prior to discharge.
Closure Date:
3 The Minneapolis VA Health Care System Director ensures that MH clinical documentation is accurate and includes documented attempts to obtain release of information and engage family in treatment, and documentation of lethality.
Closure Date:
4 The Minneapolis VA Health Care System Director verifies that all clinicians receive required training for Suicide Behavior Reporting.
Closure Date:
5 The Minneapolis VA Health Care System Director verifies that Suicide Prevention Coordinators complete Behavioral Health Autopsies within established VHA timeframes.
Closure Date:
6 The Minneapolis VA Health Care System Director ensures that the Suicide Awareness Prevention Committee document action items, follow up plans and identifies responsible staff.
Closure Date:
7 The Minneapolis VA Health Care System Director ensures that processes be strengthened to ensure the root cause analysis process is performed consistent with VHA requirements.
Closure Date:
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| 18-01963-284 | Falsification of Blood Pressure Readings at the Berea Community Based Outpatient Clinic, Lexington, Kentucky | Hotline Healthcare Inspection | ||
1 The Lexington VA Medical Center Director takes administrative action in relation to primary care provider 1, as appropriate.
Closure Date:
2 The Lexington VA Medical Center Director ensures patients impacted by blood pressure falsifications are evaluated and followed up.
Closure Date:
3 The Lexington VA Medical Center Director evaluates and takes appropriate action in relation to the four cases discussed in this report.
Closure Date:
4 The Lexington VA Medical Center Director develops processes to ensure the integrity of Veterans Health Administration Support Service Center data that supports performance metrics.
Closure Date:
5 The Lexington VA Medical Center Director ensures the development of policies and procedures governing primary care-based blood pressure readings and documentation.
Closure Date:
6 The Lexington VA Medical Center Director evaluates the practices of primary care provider 1’s licensed practical nurse, and takes appropriate administrative action, if indicated.
Closure Date:
7 The Lexington VA Medical Center Director requires retraining of Berea Community Based Outpatient Clinic staff on documentation requirements.
Closure Date:
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14957