Recommendations
2065
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-05381-258 | Postoperative Care Concerns for a Vascular Surgical Patient at the Martinsburg VA Medical Center, West Virginia | Hotline Healthcare Inspection | ||
1 The Martinsburg VA Medical Center Director evaluates the coordination of care processes at the Petersburg Community Based Outpatient Clinic and takes action as necessary based on the findings.
Closure Date:
2 The Martinsburg VA Medical Center Director ensures the development and implementation of a policy or standard operating procedure for the management of health emergencies at the Petersburg Community Based Outpatient Clinic, and Petersburg Community Based Outpatient Clinic staff receive training on the policy or standard operating procedure.
Closure Date:
3 The Martinsburg VA Medical Center Director evaluates the Petersburg Community Based Outpatient Clinic Patient Aligned Care Team patient health record documentation for accurate and clinically-relevant statements and takes action as necessary based on the findings.
Closure Date:
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| 18-04633-254 | Review of Environment of Care Conditions at Mississippi VA-Contracted Clinics | Hotline Healthcare Inspection | ||
1 The Facility Director requires a team of subject matter experts to complete comprehensive reviews of the community based outpatient clinics’ compliance with environment of care and other contract requirements, and initiate corrective action plans, as needed
Closure Date:
2 The Facility Director ensures that responsible managers and team members provide consistent oversight of community based outpatient clinics operations in accordance with contract requirements.
Closure Date:
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| 18-00619-242 | Comprehensive Healthcare Inspection Program Review of the Dayton VA Medical Center, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that the assigned staff complete at least 75 percent of all inpatient admissions and continued stay reviews and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that the interdisciplinary group review UM data on an ongoing basis and monitors compliance.
Closure Date:
4 The Chief of Staff ensures that Service Chiefs complete all required elements of Focused Professional Practice Evaluations for the determination of provider’s privileges and monitors compliance.
Closure Date:
5 The Associate Director ensures environment of care rounds are conducted in all areas of the Facility at the required frequency and monitors compliance.
Closure Date:
6 The Associate Director ensures that Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
Closure Date:
7 The Associate Director ensures all medical equipment is identified as safe for patient use and monitors compliance.
Closure Date:
8 The Chief of Staff ensures that geriatric evaluation performance improvement activities are conducted, documented, and reviewed by an appropriate leadership board and monitors compliance.
Closure Date:
9 The Chief of Staff ensures providers perform geriatric medical evaluations and monitors compliance.
Closure Date:
10 The Chief of Staff ensures that clinicians accurately identify and implement geriatric evaluation plan of care interventions and monitors compliance.
Closure Date:
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| 18-00621-245 | Comprehensive Healthcare Inspection Program Review of the VA Ann Arbor Healthcare System, Michigan | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Facility managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
Closure Date:
2 The Associate Director and Assistant Director ensure required team members participate on Environment of Care rounds and monitors compliance.
Closure Date:
3 The Facility Director ensures that reconciliation of controlled substance refills to automated dispensing units in patient care areas and returns to pharmacy stock are performed during controlled substance inspections and monitors compliance.
Closure Date:
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| 17-05401-240 | Comprehensive Healthcare Inspection Program Review of the Beckley VA Medical Center, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that service line managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that service line managers collect Ongoing Professional Practice Evaluation data utilizing assessments by providers with similar training and privileges and monitors compliance.
Closure Date:
3 The Associate Director ensures environment of care rounds are conducted at the required frequency and documented in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
4 The Associate Director ensures required team members participate on environment of care rounds and that attendance is recorded in the Comprehensive Environment of Care Assessment and Compliance Tool and monitors compliance.
Closure Date:
5 The Facility Director ensures that deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
6 The Facility Director ensures that the controlled substances inspectors consistently perform controlled substances order verification as required and monitors compliance.
Closure Date:
7 The Chief of Staff ensures that mammogram results are electronically linked to the radiology orders and monitors compliance.
Closure Date:
8 The Associate Director for Patient Care Services ensures that nursing staff involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors compliance.
Closure Date:
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| 18-01012-228 | Comprehensive Healthcare Inspection Program Review of the Chillicothe VA Medical Center, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures practitioners’ Focused Professional Practice Evaluations include clearly delineated timeframes and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that mammogram results are electronically linked to the radiology order and monitors compliance.
Closure Date:
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| 17-05400-246 | Comprehensive Healthcare Inspection Program Review of the Tomah VA Medical Center, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures that all deficiencies identified on the Annual Physical Security Survey are corrected and monitors compliance.
Closure Date:
2 The Facility 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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| 17-04156-234 | Misuse of Time and Resources within the Veterans Engineering Resource Center in Indianapolis, Indiana | Investigative | ||
1 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 1.
Closure Date:
2 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 2.
Closure Date:
3 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against Employee 3.
Closure Date:
4 The Principal Deputy Under Secretary confers with the Offices of General Counsel and Human Resources to determine the appropriate administrative action to take, if any, against other OSI VERC employees identified by the OIG for misusing government time and resources associated with this endeavor.
Closure Date:
5 The Principal Deputy Under Secretary assesses the adequacy of oversight and training for OSI VERC employees regarding the appropriate use of VA time and resources and addresses any deficiencies.
Closure Date:
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| 17-02643-239 | Review of Two Mental Health Patients Who Died by Suicide, William S. Middleton Memorial Veterans Hospital Madison, Wisconsin | Hotline Healthcare Inspection | ||
1 The Facility Director expands the Facility’s Root Cause Analysis of Patient 1’s death to include interviews of all key staff by individuals who are not their supervisors; and if additional deficiencies are identified, ensures that Facility managers complete an action plan and monitor compliance.
Closure Date:
2 The Veterans Integrated Service Network Director ensures that the Facility Director consult with the Office of Chief Counsel regarding Patient 1 and Patient 2 whether an institutional disclosure is appropriate.
Closure Date:
3 The Veterans Integrated Service Network Director ensures an ethics review is completed regarding Patient 1’s participation in the research study and provision of guidance on the voluntary participation of patients under court treatment mandates.
Closure Date:
4 The Facility Director strengthens processes to ensure that timely notification to county monitoring agencies occurs in cases of court Settlement Agreement violations.
Closure Date:
5 The Facility Director strengthens processes to ensure that Facility staff speak directly with and notify the county monitoring agency staff before an inpatient with a court Settlement Agreement is discharged.
Closure Date:
6 The Facility Director revises the mental health inpatient unit policy to include family notification with patient consent in discharge planning and ensures that Facility policy is consistent with Veterans Health Administration policy.
Closure Date:
7 The Facility Director strengthens processes to ensure that mental health clinical assessments are complete and comprehensive to include a symptom inventory and severity assessment, and monitors compliance.
Closure Date:
8 The Facility Director strengthens processes to ensure that prescribers are prescribing psychiatric medications safely including adherence to the black box warnings, and that managers complete electronic health record reviews to monitor compliance.
Closure Date:
9 The Facility Director ensures the development of a methodology for the assignment of psychiatrists as prescribers for patients with complex mental health care needs, including patients flagged as high-risk for suicide.
Closure Date:
10 The Facility Director strengthens the Ongoing Professional Practice Evaluation process to ensure that psychiatric clinical pharmacists practice within their scope of practice, and monitors compliance.
Closure Date:
11 The Facility Director ensures the development of a collaborative agreement and/or policy to address specific conditions that require oversight of psychiatric clinical pharmacists by psychiatrists in the Mental Health Service.
Closure Date:
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| 18-00617-227 | Comprehensive Healthcare Inspection Program Review of the VA Palo Alto Health Care System, California | 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 the advisors’ compliance.
Closure Date:
2 The Facility Director ensures that the Patient Safety Manager reports and documents all patient safety incidents using the Joint Patient Safety Reporting System and monitors the Patient Safety Manager’s compliance.
Closure Date:
3 The Facility Director ensures that the Patient Safety Manager submits annual reports to the leadership team for review and monitors the Patient Safety Manager’s compliance.
Closure Date:
4 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
Closure Date:
5 The Associate Director ensures the VA Police test panic alarms at the San Jose community based outpatient clinic regularly and monitors VA Police compliance.
Closure Date:
6 The Facility Director ensures that controlled substances inspectors complete monthly inspections of assigned areas and that controlled substances coordinators refrain from conducting routine inspections, and the Facility Director monitors program inspectors’ and coordinators’ compliance.
Closure Date:
7 The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substance inspections and monitors compliance.
Closure Date:
8 The Chief of Staff ensures that the geriatric evaluation program quality improvement data are reviewed and reported to the Quality, Safety and Value Council and monitors compliance.
Closure Date:
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14957