Recommendations
2079
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
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7 The Associate Director ensures that a safe and clean environment is maintained throughout the Facility and monitors compliance.
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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.
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4 The Chief of Staff ensures that clinical managers consistently collect and maintain Ongoing Professional Practice Evaluation data and monitors compliance.
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5 The Associate Director ensures Nutrition & Food Service staff store cleaning solutions separately from food items and monitors compliance.
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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.
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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.
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10 The Under Secretary for Health ensures that medication reconciliation is performed to prevent adverse drug interactions.
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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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| 17-01823-287 | Illicit Fentanyl Use and Urine Drug Screening Practices in a Domiciliary Residential Rehabilitation Treatment Program at the Bath VA Medical Center, New York | Hotline Healthcare Inspection | ||
1 The Veterans Health Administration Under Secretary for Health ensures that drug screening guidelines for VA facilities are reviewed to determine if fentanyl should be included in routine urine drug screening, and takes appropriate action.
Closure Date:
2 The Veterans Health Administration Office of Mental Health Services, Substance Use Disorders, Director considers developing and implementing a monitoring program to identify regional trends of drug abuse for facilities.
Closure Date:
3 The Veterans Integrated Service Network 2 Director evaluates laboratory processes for fentanyl test results and takes appropriate action to ensure timely turnaround times and notification of results.
Closure Date:
4 The Bath VA Medical Center Director ensures accurate tracking and monitoring of positive urine drug screening data.
Closure Date:
5 The Bath VA Medical Center Director ensures that all Domiciliary Residential Rehabilitation Treatment Program clinical staff are trained on the interpretation of urine drug screening laboratory results.
Closure Date:
6 The Bath VA Medical Center Director consults with appropriate personnel including ethics, legal counsel, privacy office, suicide prevention, and relevant Veterans Health Administration Program Office Directors to evaluate the risk identification/color-coded sticker system and ensure the practice is consistent with privacy standards and best practices.
Closure Date:
7 The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided personal protective equipment for use while conducting searches of resident belongings and rooms.
Closure Date:
8 The Bath VA Medical Center Director ensures that Domiciliary Residential Rehabilitation Treatment Program staff are provided training on conducting safe and effective searches of resident rooms and belongings.
Closure Date:
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| 16-04658-250 | Leasing Procedures Used to Acquire VA’s Wilmington Health Care Center | Audit | ||
1 The OIG recommended the Executive Director for Construction and Facilities Management establish and disseminate a formal policy for transferring contract files when transferring responsibilities to a different contracting officer.
Closure Date:
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| 18-01139-267 | Comprehensive Healthcare Inspection Program Review of the Battle Creek VA Medical Center, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures completion of at least 75 percent of all required inpatient utilization management reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that clinical managers initiate and complete Focused Professional Practice Evaluations for the determination of providers’ privileges and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
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| 17-04569-262 | Inpatient Security, Safety, and Patient Care Concerns at the Chillicothe VA Medical Center, Ohio | Hotline Healthcare Inspection | ||
1 The Chillicothe VA Medical Center Director ensures that the windows of patient care areas remain secure in accordance with Veterans Health Administration Center for Engineering and Occupational Safety and Health guidelines.
Closure Date:
2 The Chillicothe VA Medical Center Director makes certain that the Chillicothe VA Medical Center’s policy for Special Observation is followed and monitors for compliance.
Closure Date:
3 The Chillicothe VA Medical Center Director verifies that training and staff competencies are completed for Prevention and Management of Disruptive Behavior and Special Observation as required.
Closure Date:
4 The Chillicothe VA Medical Center Director confers with the Office of Chief Counsel regarding the notification of the patient’s death and discussion of institutional disclosure with the next-of-kin and takes action as appropriate.
Closure Date:
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| 18-00608-247 | Comprehensive Healthcare Inspection Program Review of the Gulf Coast Veterans Health Care System, Biloxi, Mississippi | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that an interdisciplinary facility group reviews utilization management data and monitors compliance.
Closure Date:
2 The Facility Director ensures that the Patient Safety Manager submits an annual patient safety report to Facility leaders at the completion of each fiscal year and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that Executive Committee of the Medical Staff minutes consistently reflect the documents reviewed and the rationale for the stated conclusion in order to recommend approval of clinical privileges for licensed independent practitioners and monitors compliance.
Closure Date:
4 The Chief of Staff ensures service chiefs initiate and complete Focused Professional Practice Evaluations on all newly hired licensed independent practitioners and monitors compliance.
Closure Date:
5 The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months and monitors compliance.
Closure Date:
6 The Associate Director ensures required team member participate in environment of care rounds and monitors compliance.
Closure Date:
7 The Associate Director ensures sterilized surgical instruments in the podiatry clinic are appropriately labeled with expiration dates or statements and monitors compliance.
Closure Date:
8 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
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9 The Facility Director ensures that the Alternate Controlled Substance Coordinator’s position description or functional statement includes an addendum for the Controlled Substance Coordinator’s duties and monitors compliance.
Closure Date:
10 The Facility Director ensures that monthly controlled substance inspections are completed in all required areas and monitors compliance.
Closure Date:
11 The Facility Director ensures that all controlled substance inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
Closure Date:
12 The Facility Director ensures that required pharmacy inspections are completed monthly and monitors compliance.
Closure Date:
13 The Chief of Staff ensures that providers complete suicide risk assessments within the required timeframe for patients with positive Posttraumatic Stress Disorder screens and monitors compliance.
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| 16-04558-249 | VA Policy for Administering Traumatic Brain Injury Examinations | Audit | ||
1 The Under Secretary for Benefits coordinate with the Under Secretary for Health to determine whether veterans who had received initial TBI medical examinations by VHA-contracted examiners and not by one of the four designated specialists, were unintentionally excluded from equitable relief. If additional veterans are identified, the OIG requests that those cases be referred to the VA Secretary for consideration of equitable relief.
Closure Date:
2 The Under Secretary for Benefits confirm whether the names of veterans who were not on the initial list of veterans entitled to equitable relief and later identified by VBA staff and referred for potential equitable relief were submitted to the VA Secretary for consideration. The OIG requests an update of the current status and disposition of those cases.
Closure Date:
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15039