Date Issued
|
Report Number
18-04562-205
All Reports
Date Issued
|
Report Number
18-02830-164
Open
Closed-Implemented
Closed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 2/17/2021
Develop national processes to oversee medical facility compliance with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, and coordinate the possible automated information technology solutions and inter-office and -disciplinary communications necessary to improve prescription drug monitoring program monitoring and usage in Veterans Health Administration.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/13/2021
Update the Pain Management and Opioid Safety training course to specifically address VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, query requirements and recommendations.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 12/9/2021
Ensure VA clinicians who prescribe opioids take the Pain Management and Opioid Safety training once, with annual refresher training.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Add an addendum to VHA Directive 1306, Querying State Prescription Drug Monitoring Programs, that references the VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain and ensure VA clinicians are educated and receive annual training on the Clinical Practice Guideline, to include the Centers for Disease Control and Prevention’s recommended frequency for prescription drug monitoring program queries based on the patients’ risk factors.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Direct Veterans Integrated Service Networks and their VA medical facilities to ensure local policies are consistent with VHA Directive 1306, Querying State Prescription Drug Monitoring Programs.
No. 6
to Information and Technology (OIT)
Closure Date: 2/11/2021
Develop automated information technology solutions to facilitate clinicians’ access toprescription drug monitoring program query information and reinforce the need tocomplete minimum annual VA-required prescription drug monitoring program queries.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 2/11/2020
Ensure non-VA care clinicians are in good standing and have a current state medical license that requires adherence to their state’s prescription drug monitoring program query requirements; adhere to the Veterans Affairs Opioid Safety Initiative Guidelines, including guidelines for prescription drug monitoring program queries; and are monitored to ensure appropriate corrective actions are taken if their prescribing practices are found to be inconsistent with VA/DoD Clinical Practice Guideline for Opioid Therapy for Chronic Pain.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/1/2020
Ensure Veterans Integrated Service Networks implement an effective prescription drug monitoring program oversight process that includes the review of compliance rates with medical facility directors.
Date Issued
|
Report Number
18-03526-230
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director ensures that patients denied a Veterans Choice Program referral are informed of their rights to appeal, that facility policy is consistent with Veterans Health Administration requirements, and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director verifies that the Ophthalmology and Optometry Departments’ consult management and scheduling practices are consistent with Veterans Health Administration patient indicated date timeframe requirements, incorporates patient preference, and includes receiving provider review of consults, and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director makes certain the Ophthalmology and Optometry Departments’ clinical and administrative staff receive training regarding Veterans Health Administration requirements of consult management and scheduling practices.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director reviews the Ophthalmology Department’s eye cataract intake surgery scheduling practice and ensures that overall timeliness is consistent with Veterans Health Administration directives, and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The New Mexico VA Health Care System Director conducts a timeliness review of the authorization process for non-VA Care routine eye appointments, including diabetic eye examinations, and implement action plans if the process fails to adhere to Veterans Health Administration directives.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 6/12/2020
The New Mexico VA Health Care System Director ensures the Gastroenterology Department’s consult management practices are consistent with Veterans Health Administration scheduling requirements for patient indicated dates, and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director establishes a routine review of Gastroenterology Department consult performance measures and a method to monitor identified deficiencies consistent with Veterans Health Administration requirements.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 6/26/2020
The New Mexico VA Health Care System Director evaluates whether test results within the past 12 months, ordered by the Gastroenterology Department were communicated to patients according to Veterans Healthcare Administration and facility policy, and takes action as necessary based on the results of the evaluation.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director reviews facility policy for the ordering and reporting of test results to be in alignment with Veterans Health Administration directives and completes revisions, if needed.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 3/8/2021
The New Mexico VA Health Care System Director ensures that Gastroenterology Department-ordered test results are communicated timely in accordance with Veterans Health Administration and facility policy and the timeliness is monitored through the ongoing peer review process as required by facility policy.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 12/16/2020
The New Mexico VA Health Care System Director ensures that the Gastroenterology Department Service Chief develop a process for delegating responsibility and accountability for test results and follow-up when multiple providers are involved, and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director ensures documented endoscope precleaning training for Gastroenterology Fellows, and monitors compliance.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/27/2020
The New Mexico VA Health Care System Director verifies that documentation of endoscope precleaning competencies for Gastroenterology Fellows is consistent with Veterans Health Administration requirements.
Date Issued
|
Report Number
19-07350-192
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 5/18/2020
The director of the Boston VA Regional Office reviews and corrects all work items that were cancelled or cleared by the supervisor that are likely to result in adjustments to recipients’ benefit payments.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 9/19/2019
The director of the Boston VA Regional Office confers with regional counsel to determine the appropriate administrative action to take, if any, against the supervisor.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 2/19/2020
The director of the Boston VA Regional Office implements a plan to ensure internal controls for assessing the quality of claims processed by supervisors.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 84,400.00
Date Issued
|
Report Number
18-00777-224
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that providers understand the importance of monitoring for cardiac changes, drug-drug interactions, and signs of oversedation when initiating patients on methadone.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director monitors that providers and clinical staff effectively and directly communicate with one another when providing complex patient care.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director confirms that the issue brief submitted on the identified patient contains accurate information.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director reviews the root cause analysis related to the identified patient to determine if the team composition compromised the integrity of the root cause analysis and take appropriate action if necessary.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that root cause analysis team compositions include appropriate staff and monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/3/2020
The Corporal Michael J. Crescenz VA Medical Center Director considers Peer Review for Quality Management for the additional two providers identified in this report.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Corporal Michael J. Crescenz VA Medical Center Director ensures that Unit 7E staff are knowledgeable of the observation policy, and nursing leaders are monitoring staff compliance when assigned rounding responsibilities.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director completes actions initiated or taken to resolve identified deficiencies that contributed to the events discussed in this report, and monitors for compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 8/26/2020
The Corporal Michael J. Crescenz VA Medical Center Director certifies that providers receive ongoing education on the required elements of a signed written consent prior to the initiation of methadone and ensures that providers comply with VA policy and monitors for compliance.
Date Issued
|
Report Number
19-07113-223
Date Issued
|
Report Number
18-01836-185
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/17/2019
The OIG recommended the Executive Director, VHA Procurement, ensure awareness of approval procedures and the requirement to prepare a written justification and approval document for sole-source contracts,
No. 2
to Veterans Health Administration (VHA)
Closure Date: 1/24/2020
The OIG recommended the Executive Director, VHA Procurement, establish procedures to help ensure all justification and approval documents are prepared and approved by the appropriate authority.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 9/17/2019
The OIG recommended the Executive Director, VHA Procurement, review the actions of contracting personnel involved in the cited contracts and determine whether administrative actions are warranted.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 6,034,026.00
Date Issued
|
Report Number
18-01836-184
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/17/2019
The OIG recommended that the executive director, VHA Procurement ensure awareness of approval procedures and the requirement to prepare a writtenjustification and approval document for sole-source contracts.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The OIG recommended that the executive director, VHA Procurement establish procedures to help ensure all justification and approval documents areprepared and approved by the appropriate authority.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/24/2020
The OIG recommended that the executive director, VHA Procurement review the actions of contracting personnel involved in the cited contracts anddetermine whether administrative actions are warranted.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 4/2/2020
The OIG recommended that the executive director, VHA Procurement establish formal coordination with the requiring activity to ensure adequate time isallotted for soliciting and awarding recurring services competitively.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 14,245,166.00
Date Issued
|
Report Number
18-05258-193
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/26/2020
The assistant secretary for information and technology, in conjunction with the under secretary for benefits, reevaluate the risk determination for the Beneficiary Fiduciary Field System and determine if the system should be set to a security categorization level.
No. 2
to Information and Technology (OIT),Veterans Benefits Administration (VBA)
Closure Date: 8/26/2020
The assistant secretary for information and technology, in conjunction with the under secretary for benefits, perform a risk assessment of access levels to beneficiary and fiduciary records, based upon the least privilege principle, and regularly review access to ensure that principle is enforced.
No. 3
to Information and Technology (OIT)
Closure Date: 8/26/2020
The assistant secretary for information and technology ensures audit logs within the Beneficiary Fiduciary Field System allow for management tracking of end-user access in order to reduce unauthorized browsing and the risk of data theft due to malicious activity.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 5/13/2020
The under secretary for benefits ensures field examiners submit reports with a cursory lock engaged to protect their data integrity and to prevent separation of duties issues.
Date Issued
|
Report Number
18-01836-183
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 9/12/2019
The OIG recommended that the executive director, VHA Procurement ensure awareness of approval procedures for justification and approval documents for sole source contracts.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/25/2020
The OIG recommended that the executive director, VHA Procurement establish formal coordination with the requiring activity to ensure adequate time is allotted for soliciting and awarding recurring services competitively.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 2,227,493.00
Date Issued
|
Report Number
18-05663-189
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Implement a plan to conduct a focused analysis of claims processor compliance with the requirements set forth by recent court decisions regarding examiner opinions and formulate a plan to review and take corrective action on affected claims if deemed necessary based on the results of that review.
No. 2
to Veterans Benefits Administration (VBA)
Closure Date: 4/24/2023
Develop a plan to update the rating schedule to establish more objective criteria for each level of evaluation for peripheral nerves.
No. 3
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Review all sections of the procedures manual related to peripheral nerve disability evaluations and develop a plan to make updates and clarifications where applicable.
No. 4
to Veterans Benefits Administration (VBA)
Closure Date: 11/6/2020
Review the disability benefits questionnaire forms for conditions of the spine and determine whether updates are needed to help ensure more accurate and consistent claims decisions.
No. 5
to Veterans Benefits Administration (VBA)
Closure Date: 11/3/2021
Update the Evaluation Builder tool to help users provide more accurate, comprehensive, and consistent information for claims decisions involving the spine and peripheral nerves.
Total Monetary Impact of All Recommendations
Open: $ 0.00
Closed: $ 64,800,000.00
Date Issued
|
Report Number
17-05251-194
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/29/2021
The Under Secretary for Health ensures the development and implementation of a consistent and standardized approach for hospice and palliative care documentation, consult management, and coding.
Date Issued
|
Report Number
17-03399-200
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Veterans Integrated Service Network 16 Director oversees implementation of recommendations directed to the Gulf Coast VA Health Care System Director.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that providers with previous licensure issues or malpractice cases meeting the Veterans Health Administration indicated threshold for Veterans Integrated Service Network Chief Medical Officer review, are approved by the Veterans Integrated Service Network Chief Medical Officer prior to appointment of the provider to the medical staff as required by Veterans Health Administration policy and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that Focused and Ongoing Professional Practice Evaluations are completed in accordance with Veterans Health Administration policy and monitors compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/18/2020
The Gulf Coast VA Health Care System Director ensures that actions are taken to ensure processes are followed to review and report providers, when indicated, to the National Practitioner Data Bank and state licensing boards in the timeframe required by Veterans Health Administration policy and monitors compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director reviews the circumstances surrounding the failure to report the surgeon to all licensing boards in states where the surgeon held active licenses in December 2017 and takes action, if necessary.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that the Executive Committee of the Medical Staff’s meeting minutes provide sufficient detail to allow tracking of medical management decisions and problem solving and monitors compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 9/13/2020
The Gulf Coast VA Health Care System Director determines the scope of previously administratively closed incomplete notes in patient electronic health records that have been administratively closed to ensure compliance with Veterans Health Administration policy and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 9/13/2020
The Gulf Coast VA Health Care System Director tracks and monitors the process used to administratively close incomplete electronic health record notes by providers who no longer work at the Gulf Coast VA Health Care System.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures and monitors that protected information contained in the Facility Surgical Workgroup minutes is maintained on a secure intranet site in alignment with Veterans Health Administration policy.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director confirms that patients’ care whose death occurred within 30 days of a surgical procedure are reviewed and monitors compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 7/21/2020
The Gulf Coast VA Health Care System Director ensures that required staff maintain basic life support and advanced cardiac life support certification as required by Veterans Health Administration policy and monitors compliance.
No. 12
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Gulf Coast VA Health Care System Director makes sure that required Gulf Coast Health Care System services submit monthly basic life support and advanced cardiac life support compliance reports to the Critical Care Committee.
No. 13
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director verifies that monthly basic life support and advanced cardiac life support compliance reports are provided to the Executive Committee of the Medical Staff as required by Gulf Coast VA Health Care System policy and monitors for compliance.
No. 14
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes sure that Patient Safety Committee meeting minutes reflect a discussion of patient safety activities as required by Gulf Coast VA Health Care System policy and monitors compliance.
No. 15
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes certain that past and future adverse events are reported to the patient safety manager as defined in Gulf Coast Health Care System policy and monitors compliance.
No. 16
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that at least one proactive risk assessment is completed every 18 months for The Joint Commission accredited programs as required by Veterans Health Administration policy and monitors compliance.
No. 17
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director makes certain that an effective process is in place to identify and review cases where an institutional disclosure may be indicated and monitors compliance.
No. 18
to Veterans Health Administration (VHA)
Closure Date: 5/12/2020
The Gulf Coast VA Health Care System Director reviews the eight identified events that met criteria for consideration of an institutional disclosure as required by Veterans Health Administration policy and takes action as warranted.
No. 19
to Veterans Health Administration (VHA)
Closure Date: 2/6/2020
The Gulf Coast VA Health Care System Director ensures that Administrative Investigation Boards are completed within the 45-calendar day timeframe required by Veterans Health Administration policy and monitors compliance.
Date Issued
|
Report Number
18-02988-198
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Veterans Integrated Service Network Director ensures that Memphis VA Medical Center leaders assess staffing needs, to include factors impacting the ability to recruit and retain staff, develop plans to improve staffing and assist in hiring to staff Pathology and Laboratory Medicine Service as required by the Clinical Laboratory Improvement Amendment and Veterans Health Administration.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director verifies the development and implementation of a formal process to track surgical pathology specimens sent out of the Memphis VA Medical Center for processing and monitors compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures a comprehensive assessment of the Pathology and Laboratory Medicine Service to identify specific root causes of surgical pathology specimen delays and ensure steps are taken to prevent risk of future occurrences.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures that Pathology and Laboratory Medicine Service leaders provide an ongoing, comprehensive Quality Management program that identifies the availability of accurate, reliable, and timely test results, and reports to the ordering providers.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 7/30/2020
The Memphis VA Medical Center Director ensures compliance with required surgical pathology Quality Assurance policies and practices, and that Memphis VA Medical Center leaders monitor compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director ensures that an ongoing process is developed and implemented for Memphis VA Medical Center oversight of Pathology and Laboratory Medicine Service quality data, that includes documentation of the discussion of quality assurance and analysis of the data and the development of action plans as needed.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/11/2020
The Memphis VA Medical Center Director verifies that all Pathology and Laboratory Medicine Service employees that perform patient testing have updated competencies and documented training on their assigned duties.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/28/2020
The Memphis VA Medical Center Director ensures that Memphis VA Medical Center leaders understand the importance of the issue brief process and comply with the Deputy Under Secretary for Health and Operations Guidance.
Date Issued
|
Report Number
19-07429-195
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 1/28/2021
The West Palm Beach VA Medical Center Director ensures that mental health multidisciplinary treatment plans are completed in accordance with Veterans Health Administration and The Joint Commission guidelines.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding the Interdisciplinary Safety Inspection Team and its associated functions.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures immediate compliance with Veterans Health Administration guidelines regarding Mental Health Environment of Care Checklist training prior to entry on unit 3C and annually thereafter.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/16/2020
The West Palm Beach VA Medical Center Director ensures that the Employee Education Service staff assigns Mental Health Environment of Care Checklist on-line training modules to employees according to their duties and assignments.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The West Palm Beach VA Medical Center Director ensures that deficiencies identified during the Mental Health Environment of Care Checklist inspections are abated according to VHA guidelines, and that appropriate risk mitigation strategies are implemented as needed.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 5/28/2020
The Veterans Integrated Service Network Director ensures that the appropriate Veterans Integrated Service Network level staff complies with guidelines to review semi-annual reports and follow-up to ensure abatement of deficiencies prior to item closure on the Mental Health Environment of Care Checklist.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 3/18/2021
The Under Secretary for Health takes action to ensure that the Mental Health Environment of Care Checklist Work Group reviews and ranks hazards as submitted through the Patient Safety Assessment Tool, and ensures abatement (or waiver of abatement), as indicated.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that patient safety and law enforcement cameras are installed, tested, and monitored according to West Palm Beach VA Medical Center and Veterans Health Administration guidelines.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that a policy on 15-minute safety rounding expectations be developed, and that all permanent and temporarily-assigned staff performing 15-minute safety rounding on unit 3C receive appropriate training regarding their duties.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director develops a mechanism to confirm staff compliance with 15-minute rounding requirements.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 4/28/2020
The West Palm Beach VA Medical Center Director ensures that managers and leaders with mental health, environment of care, and patient safety-related responsibilities are knowledgeable about areas and policies governing the areas under their purview.
Date Issued
|
Report Number
19-00006-191
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 11/3/2020
The facility director makes certain that all required representatives consistently participate in interdisciplinary reviews of utilization management data and monitors representatives’ compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 4/7/2020
The chief of staff ensures that service chiefs initiate and complete focused professional practice evaluations and monitors service chiefs’ compliance.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that service chiefs include the review of service-specific data for ongoing professional practice evaluations and monitors service chiefs’ compliance.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff ensures service chiefs include review of ongoing professional practice evaluation data in the determination to continue current privileges and monitors the service chiefs’ compliance.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that the Medical Executive Council meeting minutes consistently reflect the review of focused and ongoing professional practice evaluation results in the decision to recommend continuation of initially granted or ongoing privileges and monitors committee’s compliance.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The associate director ensures that staff label multi-dose medication vials with an expiration date upon opening and monitors clinical staff’s compliance.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The associate director makes certain that VA police document response time for panic alarm testing at the locked mental health inpatient unit and monitors compliance.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director ensures that electronic access for performing or monitoring controlled substances balance adjustments is limited to appropriate staff and monitors compliance.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The facility director ensures that a formal process for reviewing override reports is implemented and monitors compliance.
No. 10
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff makes certain that providers complete military sexual trauma mandatory training within the required timeframe and monitors providers’ compliance.
No. 11
to Veterans Health Administration (VHA)
Closure Date: 1/9/2020
The chief of staff ensures that a backup call schedule is maintained for emergency department providers and social workers and monitors compliance.
Date Issued
|
Report Number
18-01214-157
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Establish a policy that formally defines “medical document backlog”—specifically, the age of unscanned and unindexed medical documentation.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 11/18/2020
Implement formal controls to monitor medical document backlogs—specifically, the description of unscanned and unindexed documents, size of the backlog, and age of health records—as well as subsequent actions to reduce the backlogs.
No. 3
to Veterans Health Administration (VHA)
Closure Date: 5/20/2020
Direct Veterans Integrated Service Networks and facilities with a backlog to allocate additional resources to help clear them.
No. 4
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Implement policy to require chiefs of Health Information Management to notify facility directors when a medical document backlog exists and to take appropriate action.
No. 5
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
Assess the scanning process, including staffing and productivity levels, within each facility to ensure authorized staffing levels can support future workload.
No. 6
to Veterans Health Administration (VHA)
Closure Date: 1/25/2022
Ensure facility directors act on staffing level assessments and obtain the necessary resources within scanning departments.
No. 7
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Implement standardized quality assurance monitoring procedures to improve accurate updating of patients’ electronic health records and completion of corrective actions when errors are identified.
No. 8
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Ensure original documents are retained until the scanning supervisor or designee verifies that scanning staff have met quality assurance monitoring standards established in Recommendation 7.
No. 9
to Veterans Health Administration (VHA)
Closure Date: 5/18/2021
Develop procedures to ensure facility directors provide adequate document scanning/indexing training, consistent with Veterans Health Administration Handbook 1907.07, prior to allowing employees to scan/index documents without direct supervision and as needed for corrective actions.
Date Issued
|
Report Number
16-03597-171
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Information and Technology (OIT)
Closure Date: 1/9/2020
The assistant secretary for information and technology and chief information officer should enforce current required project management processes with improved oversight to ensure project planning requirements are adequately defined and supported before starting information technology projects.
Date Issued
|
Report Number
19-00004-187
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 3/16/2020
The Edward Hines, Jr. VA Hospital Director evaluates the current surgery scheduling practices to determine if changes are required to improve communication processes, and takes action as necessary.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/16/2020
The Edward Hines, Jr. VA Hospital Director ensures that documentation is in place that determines part-time physicians’ tours of duty and responsibilities for time and attendance and monitors compliance.
Date Issued
|
Report Number
19-00501-175
OpenClosed-ImplementedClosed-Not ImplementedNo. 1
to Veterans Health Administration (VHA)
Closure Date: 7/30/2020
The Under Secretary for Health expedites the development of a National Suicide Prevention Program policy and procedure to delineate the deactivation process of High Risk for Suicide Patient Record Flags and monitors compliance.
No. 2
to Veterans Health Administration (VHA)
Closure Date: 3/18/2020
The San Diego Healthcare System Director ensures that processes be strengthened to ensure accurate patient medication information is reflected in medication reconciliation documentation and monitors compliance.