Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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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| 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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| 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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15039