Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 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.
Closure Date:
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.
Closure Date:
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).
Closure Date:
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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| 18-01496-301 | 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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| 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.
Closure Date:
6 The Associate Director ensures weekly inspections of the emergency power supply system are performed and documented and monitors compliance.
Closure Date:
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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| 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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| 17-04875-308 | 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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| 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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15039