Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01770-188 | Intraoperative Radiofrequency Ablation and Other Surgical Service Concerns, Samuel S. Stratton VA Medical Center, Albany, New York | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director ensures that the Facility’s credentialing and privileging program is reviewed for integration of key functions of quality oversight, including the use of quality data for Focused Professional Practice Evaluation and Ongoing Professional Practice Evaluation processes and surgical Peer Review program.
Closure Date:
2 The Facility Director ensures that the Facility Peer Review program meets all Veterans Health Administration requirements.
Closure Date:
3 The Facility Director ensures that Surgery Service’s professional practice evaluations include performance data to support provider privileges and contain accurate data.
Closure Date:
4 The Facility Director ensures that a process is developed and implemented to document, report, and track patient cases discussed in the Liver Tumor Board and that meeting minutes are completed and forwarded to oversight groups.
Closure Date:
5 The Facility Director ensures that a process is implemented to track, monitor, and report intraoperative radiofrequency ablation outcomes to Facility and Quality Management leaders.
Closure Date:
6 The Facility Director ensures that the Office of General Counsel is consulted on the three patients with missed or partially missed tumors after intraoperative radiofrequency ablation to determine if institutional disclosure might be appropriate.
Closure Date:
7 The Facility Director ensures that the five additional intraoperative radiofrequency ablation patients the Office of Inspector General referred to the Facility, and any other patients who had intraoperative radiofrequency ablation done by Surgeon A, are reviewed by clinicians with qualifications to assess the outcome of these procedures and actions taken as appropriate.
Closure Date:
8 The Facility Director ensures an external review of intraoperative radiofrequency ablation processes is obtained to identify possible causes of missed tumors and methods to improve practice and outcomes.
Closure Date:
9 The Facility Director ensures that Human Resources and the Office of General Counsel are consulted to determine the appropriate actions, if any, including consideration for ethics review, for staff who were not forthcoming with patients on outcomes of intraoperative radiofrequency ablation.
Closure Date:
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| 17-01857-264 | Comprehensive Healthcare Inspection Program Review of the Bay Pines VA Healthcare System, Florida | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures that floors in patient care areas are clean and monitors compliance.
Closure Date:
2 The Facility Director ensures that the Alternate Controlled Substances Coordinator’s position description or functional statement includes the Control Substance Coordinator’s duties and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that the Geriatric Evaluation Social Worker performs the required comprehensive psychosocial assessment and monitors compliance.
Closure Date:
4 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 prevention training and monitors compliance.
Closure Date:
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| 16-01913-223 | Use of Not Otherwise Classified Codes for Prosthetic Limb Components | Audit | ||
1 The Executive in Charge, Veterans Health Administration, should review the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (August 2011, March 2013, and August 2013), coordinate with appropriate officials to determine which Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes are appropriate to classify these items for reimbursement, and issue revised guidance.
Closure Date:
2 The Executive in Charge, Veterans Health Administration, should coordinate with appropriate officials to establish a formal oversight and reporting structure that defines the roles and the responsibilities of the Prosthetic and Sensory Aids Service Orthotic and Prosthetic L Code Committee, as well as who has the authority to approve recommendations for the use of the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II L codes to classify specific prosthetic components for reimbursement.
Closure Date:
3 The Executive in Charge, Veterans Health Administration, should develop and implement effective processes and procedures to monitor the use of Not Otherwise Classified codes and communicate these procedures to the Veterans Integrated Service Networks to ensure compliance with Veterans Health Administration Directive 1045, Healthcare Common Procedure Coding System (HCPCS) List for Prosthetic Limb and/or Custom Orthotic Device Prescription (December 30, 2013) and the Centers for Medicare and Medicaid Services’ Healthcare Common Procedure Coding System Level II Coding Procedures.
Closure Date:
4 The Executive in Charge, Veterans Health Administration, should coordinate with the appropriate officials to develop and implement processes and procedures to ensure any pricing guidance with regard to the pricing of prosthetic items classified using a Not Otherwise Classified code is developed and concurred with by VA Office of General Counsel and Veterans Health Administration’s Procurement and Logistics Office prior to issuance.
Closure Date:
5 The Executive in Charge, Veterans Health Administration, should issue corrected guidance to replace the Prosthetic and Sensory Aids Service Ottobock microprocessor knee instructions (March 2013 and August 2013) and the prosthetic limb contract template issued in August 2014, by coordinating with appropriate officials to develop and implement pricing guidance to ensure VA pays a fair and reasonable price for items classified using a Not Otherwise Classified code.
Closure Date:
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| 18-00612-260 | Comprehensive Healthcare Inspection Program Review of the VA St. Louis Health Care System, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data every six months 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 Alternate Controlled Substances Coordinator are included in the employee position description or functional statement and monitors compliance.
Closure Date:
5 The Facility Director ensures that Controlled Substances Inspectors are appointed in writing prior to performing inspector duties and monitors compliance.
Closure Date:
6 The Facility Director ensures that controlled substances inspections are completed monthly in all clinical areas and monitors compliance.
Closure Date:
7 The Chief of Staff ensures that ordering providers are notified of all mammography results and monitors compliance.
Closure Date:
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| 18-00600-259 | Comprehensive Healthcare Inspection Program Review of the Ralph H. Johnson VA Medical Center, Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
2 The Associate Director ensures that Facility managers maintain clean floors in patient care areas and monitors compliance.
Closure Date:
3 The Associate Director ensures that Facility managers ensure that damaged equipment in patient care areas is repaired or removed from service and that Facility managers monitor compliance.
Closure Date:
4 The Chief of Staff ensures that mammogram reports are scanned into Veterans Health Information Systems and Technology Architecture Imaging and are viewable by all members of the healthcare team and that Facility managers monitor compliance.
Closure Date:
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| 18-01011-253 | Comprehensive Healthcare Inspection Program Review of the John J. Pershing VA Medical Center, Poplar Bluff, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
2 The Associate Director ensures the emergency power supply system inspections are performed weekly and monitors compliance.
Closure Date:
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| 17-04919-210 | Processing Inaccuracies Involving Veterans' Intent to File Submissions for Benefits | Audit | ||
1 The OIG recommended the Under Secretary for Benefits take steps to prioritize the modernization of functionality within the Veterans Benefits Management System to assist rating personnel with assigning correct effective dates related to intent to file.
Closure Date:
2 The OIG recommended the Under Secretary for Benefits implement a plan to conduct a special review of claims with intent to file submissions from March 24, 2015, through September 30, 2017, during which payment changes occurred, to determine whether rating personnel assigned correct effective dates when awarding compensation benefits.
Closure Date:
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| 17-05248-241 | Denied Posttraumatic Stress Disorder Claims Related to Military Sexual Trauma | Audit | ||
1 The Under Secretary for Benefits reviews all denied military sexual trauma related claims since the beginning of FY 2017, determines whether all required procedures were followed, takes corrective action based on the results of the review, renders a new decision as appropriate, and reports the results back to the Office of Inspector General.
Closure Date:
2 The Under Secretary for Benefits focuses processing of military sexual trauma related claims to a specialized group of Veterans Service Representatives and Rating Veterans Service Representatives.
Closure Date:
3 The Under Secretary for Benefits requires an additional level of review for all denied military sexual trauma related claims and holds the second level reviewers accountable for accuracy.
Closure Date:
4 The Under Secretary for Benefits conducts special focused quality improvement reviews of denied military sexual trauma related claims and takes corrective action as needed.
Closure Date:
5 The Under Secretary for Benefits updates the current training for processing military sexual trauma related claims, monitors the effectiveness of the training, and takes additional actions as necessary.
Closure Date:
6 The Under Secretary for Benefits updates the development checklist for military sexual trauma related claims to include specific steps claims processors must take in evaluating such claims in accordance with applicable regulations, and requires claims processors to certify that they completed all required development action for each military sexual trauma-related claim.
Closure Date:
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| 18-00618-261 | Comprehensive Healthcare Inspection Program Review of the Erie VA Medical Center, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that the peer reviewer identifies one or more of the Eleven Aspects for Review of Care in the completion of peer reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that the Ongoing Professional Practice Evaluation process includes the development and utilization of service- and practitioner-specific data and monitors compliance.
Closure Date:
3 The Associate Director of Patient Care Services ensures that staff follow medication administration, storage, and disposal policies and monitors compliance.
Closure Date:
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| 17-04003-222 | Program of Comprehensive Assistance for Family Caregivers: Management Improvements Needed | Audit | ||
1 The Executive in Charge, Veterans Health Administration, will establish a governance environment for the Program of Comprehensive Assistance for Family Caregivers to ensure medical facilities process veteran applications within the required 45-day timeliness standard, consistently monitor veterans and their caregivers, adequately document the results and changes in veterans’ health status, and adjust the level of support provided or discharge veterans and their caregivers, as appropriate.
Closure Date:
2 The Executive in Charge, Veterans Health Administration, will take steps to ensure caregiver support coordinators are properly applying eligibility criteria with processes, such as pre- or post-approval reviews, to ensure the accuracy of all veteran eligibility determinations.
Closure Date:
3 The Executive in Charge, Veterans Health Administration, will update Directive 1152, Caregiver Support Program, to include a well-defined process for documenting changes in veterans’ health conditions during monitoring sessions to determine if those changes warrant a reassessment of the need for care or the level of care.
Closure Date:
4 The Executive in Charge, Veterans Health Administration, will establish assessment guidelines that caregiver support coordinators should follow when a veteran’s need for care changes.
Closure Date:
5 The Executive in Charge, Veterans Health Administration, will make sure that Veterans Integrated Service Network directors designate program leads at the network level with responsibility for Program of Comprehensive Assistance for Family Caregivers oversight.
Closure Date:
6 The Executive in Charge, Veterans Health Administration, will assess the extent to which current staffing levels at medical facilities are adequate to implement the Program of Comprehensive Assistance for Family Caregivers, as intended.
Closure Date:
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14957