Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-03382-294 | Alleged Inadequate Mental Health Treatment at the Dayton VA Medical Center, Ohio | Hotline Healthcare Inspection | ||
1 The Dayton VA Medical Center Director ensures that the Mental Health Residential Rehabilitation Treatment Program nursing staff complete validated clinical scales to assess and quantify the severity of withdrawal symptoms for patients with opioid use disorder, as ordered.
Closure Date:
2 The Dayton VA Medical Center Director ensures that the Mental Health Residential Rehabilitation Treatment Program provides timely therapeutic activity schedules to residents, including weekend treatment activities.
Closure Date:
3 The Dayton VA Medical Center Director consults with the Veterans Health Administration Mental Health Residential Rehabilitation Treatment Program Office to evaluate whether the resident privileging levels program was congruent with the goals of the Mental Health Residential Rehabilitation Treatment Program, and take action as necessary.
Closure Date:
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| 17-05228-279 | Alleged Nonacceptance of VA Authorizations by Community Care Providers, Fayetteville, North Carolina | Audit | ||
1 The Executive in Charge, Office of the Under Secretary for Health, ensure community care provider participation is effectively monitored at the local level to mitigate the risk of unidentified gaps in specialty care coverage.
Closure Date:
2 The Executive in Charge, Office of the Under Secretary for Health, ensure the Veterans Integrated Service Network 6 Claims Adjudication and Reimbursement office identify and dedicate the appropriate number of staff needed to timely process Non-VA Care medical claims.
Closure Date:
3 The Executive in Charge, Office of the Under Secretary for Health, ensure the Veterans Integrated Service Network 6 Claims Adjudication and Reimbursement office implements specific controls to ensure staff are not inaccurately rejecting Non-VA care claims, or rejecting claims for the wrong reasons.
Closure Date:
4 The Executive in Charge, Office of the Under Secretary for Health, implement controls to ensure VA staff timely resolve medical claim inquiries from community providers.
Closure Date:
5 The Executive in Charge, Office of the Under Secretary for Health, implement oversight procedures to ensure community care contractors effectively notify community providers when they reject their claims.
Closure Date:
6 The Executive in Charge, Office of the Under Secretary for Health, implement oversight procedures to ensure community care contractors effectively resolve medical claim inquiries from community providers.
Closure Date:
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| 18-00613-275 | Comprehensive Healthcare Inspection Program Review of the Veterans Health Care System of the Ozarks, Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that an interdisciplinary Facility group review Utilization Management data and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that Service Chiefs consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
3 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
4 The Facility Director ensures that the duties of the controlled substance coordinator and alternate controlled substance coordinator are included in the employees’ position descriptions or functional statements and monitors compliance.
Closure Date:
5 The Facility Director ensures controlled substance inspectors complete controlled substance order verifications and monitors compliance.
Closure Date:
6 The Chief of Staff ensures staff link the mammography results to the radiology order and monitors compliance.
Closure Date:
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| 17-03347-290 | Alleged Quality of Care Issues in the Community Living Centers, Northport VA Medical Center, New York | Hotline Healthcare Inspection | ||
1 The Northport VA Medical Center Director makes certain that staff conduct post-Code Blue debriefings as required and that compliance is monitored.
Closure Date:
2 The Northport VA Medical Center Director ensures the collection, review, and analysis of data following each Emergency Response Team event response and that those involving resuscitative care are reviewed by the Facility Cardiopulmonary Resuscitation Committee, and that compliance is monitored.
Closure Date:
3 The Northport VA Medical Center Director confirms that a review of the Community Living Centers’ meal staffing process is performed to evaluate the need for designation of a staff person responsible for assigning (both nurse and interdisciplinary team) and monitoring staffing levels in the dining hall throughout meal times and takes appropriate action.
Closure Date:
4 The Northport VA Medical Center Director completes a review of the meal delivery process in the CLCs to confirm and document menu selection and diet type at the time that meal trays are served to the patient and makes policy updates, if warranted.
Closure Date:
5 The Northport VA Medical Center Director verifies that Community Living Centers’ safety rounds are conducted and documented, as required, and that compliance is monitored.
Closure Date:
6 The Northport VA Medical Center Director confers with Office of General Counsel to determine if an institutional disclosure of Patient A’s care is warranted.
Closure Date:
7 The Northport VA Medical Center Director obtains peer reviews of the care provided by practitioners (including supervisors in the case of the resident physicians) during the emergency management of Patient A while in the Community Living Center and Emergency Department.
Closure Date:
8 The Northport VA Medical Center Director reviews and updates, as warranted, Facility policies and practices related to emergency medical response (such as obtaining emergent intravenous access) and adequate medical oversight, and all staff (including resident physicians) complete training and compliance is monitored.
Closure Date:
9 The Veterans Integrated Service Network 2 Director oversees and provides assistance to the Northport VA Medical Center Director in the review and update of Facility policies and practices on emergency medical response and adequate medical oversight.
Closure Date:
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| 17-03347-293 | Alleged Inadequate Nurse Staffing Led to Quality of Care Issues in the Community Living Centers at the Northport VA Medical Center, New York | Hotline Healthcare Inspection | ||
1 The Northport VA Medical Center Director completes a full review of Community Living Center nurse staffing to ensure authorized full-time employee equivalents align with census and recommended nursing hours per patient day and that modifications (if any) are reflected on the Nursing Service organizational chart.
Closure Date:
2 The Northport VA Medical Center Director continues efforts to recruit and hire for Community Living Center nursing vacancies and ensures that, until optimal staffing is attained, alternate staffing strategies are consistently available to meet resident care needs.
Closure Date:
3 The Northport VA Medical Center Director reviews and identifies processes that improve management of overtime practices to ensure quality of care and responsible use of financial resources and determines if actions need to be taken.
Closure Date:
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| 17-03347-285 | Alleged Poor Quality of Care in a Community Living Center at the Northport VA Medical Center, New York | Hotline Healthcare Inspection | ||
1 The Northport VA Medical Center Director ensures a review of Community Living Center 3’s 24-Hour Observation Flow Sheets is completed to determine the accuracy of documentation entered by all shifts for the past three months, beginning with the date of receipt of this report, and initiates an action plan to correct identified deficiencies.
Closure Date:
2 The Northport VA Medical Center Director makes certain that an updated quality management review is completed, to include evaluation of medication management throughout the discussed patient’s admission, and disseminates findings to staff and service lines involved in the care of the patient.
Closure Date:
3 The Northport VA Medical Center Director ensures that the Office of General Counsel is consulted regarding the patient’s missed anticoagulation doses to determine if institutional disclosure to the patient’s family is appropriate per Veterans Health Administration Handbook 1004.08, Disclosure of Adverse Events to Patients.
Closure Date:
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| 18-01018-281 | Comprehensive Healthcare Inspection Program Review of the Northport VA Medical Center, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff 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 implementation of root cause analysis actions and provides feedback of results to the reporting individuals or departments and monitors compliance.
Closure Date:
3 The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to the Facility leaders and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that Service Chiefs complete and report Focused and Ongoing Professional Practice Evaluations to the Professional Standards Board for determination of provider privileges and monitors the Service Chiefs’ compliance.
Closure Date:
5 The Associate Director ensures environment of care rounds are conducted in patient care areas of the Facility at the required frequency and monitors compliance.
Closure Date:
6 The Associate Director ensures a proactive pest control management program is in place throughout the Facility 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 that a consistent mechanism or method is in place for clinical staff to be confident that patient care equipment is safe and functional and monitors compliance.
Closure Date:
9 The Associate Director ensures the mental health seclusion room flooring provides cushioning.
Closure Date:
10 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:
11 The Chief of Staff ensures that geriatric evaluation performance improvement activities are reviewed by a Facility leadership board and monitors compliance.
Closure Date:
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| 18-00620-277 | Comprehensive Healthcare Inspection Program Review of the Roseburg VA Health Care System, Oregon | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly defined timeframes and monitors the clinical managers’ compliance.
Closure Date:
2 The Chief of Staff ensures Focused Professional Practice Evaluations are completed by providers with similar training and privileges and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that the Executive Council of Medical Staff uses the results of Focused Professional Practice Evaluations in the decision to recommend continuation of initially granted privileges and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that clinical managers consistently collect and maintain Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
5 The Associate Director ensures Nutrition & Food Service staff store cleaning solutions separately from food items and monitors compliance.
Closure Date:
6 The Interim Director ensures that controlled substances inspectors complete routine monthly controlled substance inspections and that controlled substances coordinators refrain from conducting routine inspections and monitors compliance.
Closure Date:
7 The Interim Director ensures that reconciliation of controlled substance returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Closure Date:
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| 16-00538-282 | Review of Pain Management Services in Veterans Health Administration Facilities | National Healthcare Review | ||
1 The Under Secretary for Health ensures that VA facilities have formal processes in place for providers to access state prescription drug monitoring programs to reconcile medications dispensed by private providers and those dispensed by VA, and that this process is in compliance with the providers’ state licensing requirements.
Closure Date:
2 The Under Secretary for Health evaluates the use of facility-specific panel readjustments or other means of increasing resources for primary care providers who manage chronic pain conditions for a significant proportion of his/her panel and takes action as appropriate.
Closure Date:
3 The Under Secretary for Health evaluates and determines the adequacy of the number of pain specialists at each facility through formalized assessments and takes action as appropriate.
Closure Date:
4 The Under Secretary for Health ensures that VA facilities without pain specialists have formalized designated resources of pain care provided by providers.
Closure Date:
5 The Under Secretary for Health evaluates the use of pain assessment tools across the Veterans Health Administration to ensure that those tools used by facilities provide information that improves oversight to patients who are treated for chronic pain conditions.
Closure Date:
6 The Under Secretary for Health develops a formal evaluation of the provision of pain management services within VA to complement the Opioid Safety Initiative.
Closure Date:
7 The Under Secretary for Health ensures that VA’s practice of routine and random urine drug tests both prior to initiating and during take-home opioid therapy to confirm the use of opioids is in alignment with guidelines.
Closure Date:
8 The Under Secretary for Health ensures that opioid patients with active (not in remission) substance use disorder undergo urine drug testing and receive treatment for the substance use disorder.
Closure Date:
9 The Under Secretary for Health evaluates and determines that VA’s practice of prescribing and dispensing benzodiazepines concurrently with opioids is in alignment with guidelines.
Closure Date:
10 The Under Secretary for Health ensures that medication reconciliation is performed to prevent adverse drug interactions.
Closure Date:
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| 17-02679-283 | Delays and Deficiencies in Obtaining and Documenting Mammography Services at the Atlanta VA Health Care System, Decatur, Georgia | Hotline Healthcare Inspection | ||
1 The Atlanta VA Health Care System Director ensures that a review is conducted of patients with mammography orders in an active, pending, or scheduled status as of October 28, 2015, to ensure that clinical care was provided and results are documented in the electronic health record.
Closure Date:
2 The Atlanta VA Health Care System Director makes certain that Medical Center Memorandum 11-04, Health Care for Women Veterans, May 17, 2016, is updated to reflect current Facility processes, including but not limited to mammography coordinator responsibilities.
Closure Date:
3 The Atlanta VA Health Care System Director ensures compliance with Veterans Health Administration Directive 1232(1), Consult Processes and Procedures (amended September 23, 2016), including the completion of mammograms by the order date or the date the physician requested the study be completed and that a process is established for review when consults exceed established timeliness thresholds.
Closure Date:
4 The Atlanta VA Health Care System Director improves mammography processes to schedule appointments and receive, account for, scan, upload, and provide external diagnostic imaging results to the appropriate clinical areas and Veterans Health Administration providers and that the process is monitored.
Closure Date:
5 The Atlanta VA Health Care System Director confirms that clinical appropriateness reviews of mammography consults are performed to ensure that the correct imaging study is ordered for the patient’s clinical presentation and that performance of reviews is monitored.
Closure Date:
6 The Atlanta VA Health Care System Director verifies that providers who are trained in provision of women veterans health care are designated as Women’s Health Primary Care Providers, have the required number of women assigned to their panel, and provide gender specific care in accordance with Veterans Health Administration policy.
Closure Date:
7 The Atlanta VA Health Care System Director provides executive level oversight of the Women Veterans Program to ensure that service level functions are coordinated, processes are streamlined, and identified actions are tracked to resolution.
Closure Date:
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14957