Recommendations
1324
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 10-01937-63 | Review of Allegations at VA Medical Center, Providence, Rhode Island | Audit | ||
| 12-03346-69 | Review of VHA's Minor Construction Program | Audit | ||
1 We recommended the Under Secretary for Health publish policy for the Minor Construction Program.
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2 We recommended the Under Secretary for Health develop procedures to ensure minor construction projects are executed within their approved scope.
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3 We recommended the Under Secretary for Health review the seven minor construction projects that were integrated into three combined projects which exceeded the $10 million construction appropriation limit to determine if major construction projects were created, and take appropriate administrative action.
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4 We recommended the Under Secretary for Health implement a mechanism to ensure medical facility funding is not used to supplement minor construction projects.
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5 We recommended the Under Secretary for Health ensure internal program reviews of the Minor Construction Program are performed.
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6 We recommended the Under Secretary for Health strengthen minor construction Project Tracking Reports to ensure information is accurate and sufficient to monitor program performance.
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| 12-03741-61 | Combined Assessment Program Review of the VA Maine Healthcare System,Augusta, Maine | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are reported to the PRC.
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2 We recommended that processes be strengthened to ensure that EHR quality reviews are analyzed at least quarterly.
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3 We recommended that processes be strengthened to ensure that actions taken when data analyses indicated problems or opportunities for improvement are consistently followed to resolution by the Health Information Management Committee, Special Care Unit Committee, and the Systems Redesign Collaborative teams.
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4 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks and that oxygen tanks are not stored near electrical circuit breaker panels.
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5 We recommended that processes be strengthened to ensure that required preventive maintenance is performed on designated equipment in the physical therapy clinics.
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6 We recommended that processes be strengthened to ensure that all non-HPC staff receive end-of-life training.
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| 11-00317-37 | Audit of Vocational Rehabilitation and Employment Program's Self-Employment Services at Eastern and Central Area Offices | Audit | ||
1 We recommended the Under Secretary for Benefits implement procedures to improve the accuracy of data in Corporate WINRS.
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2 We recommended the Under Secretary for Benefits perform a data integrity review comparing Corporate WINRS to active self-employment Counseling/Evaluation/Rehabilitation files and take corrective action as needed.
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3 We recommended the Under Secretary for Benefits develop and implement performance measures that evaluate the success of self-employment services.
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4 We recommended the Under Secretary for Benefits provide training to Eastern and Central area Vocational Rehabilitation and Employment staff to ensure they understand the criteria used to determine rehabilitation status for participants in self-employment services.
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5 We recommended the Under Secretary for Benefits include guidance in Veterans Benefits Administration's Manual M28 to clarify when it is appropriate to provide services for veterans with an established business under a self-employment plan.
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6 We recommended the Under Secretary for Benefits revise Veterans Benefits Administration's Manual M28, Part IV, to ensure Veterans Benefits Administration's guidance aligns with Title 38, Code of Federal Regulations, for approval of self-employment plans.
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| 12-03071-53 | Combined Assessment Program Review of the Fayetteville VA Medical Center, Fayetteville, North Carolina | Comprehensive Healthcare Inspection Program | ||
| 12-03075-52 | Combined Assessment Program Review of the Miami VA Healthcare System, Miami, Florida | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that EOC-Safety and IC Committee minutes reflect sufficient data analysis, actions implemented, and tracking of items to closure.
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2 We recommended that a comprehensive EOC inspection of the ED be conducted and that appropriate actions be taken to correct IC and safety deficiencies.
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3 We recommended that processes be strengthened to ensure that emergency exits are not obstructed.
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4 We recommended that processes be strengthened to ensure that MSDS inventory lists and hazardous materials information binders are current and that staff are trained on accessing the electronic MSDS materials.
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5 We recommended that processes be strengthened to ensure that safety inspections are conducted on all ceiling lifts in the SCI Center and SCI outpatient clinic.
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6 We recommended that processes be strengthened to ensure that medications, chemicals, solutions, and cleaning carts are properly secured.
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7 We recommended that processes be strengthened to ensure that monthly MH RRTP self-inspections and daily room inspections are conducted and that inspection reports contain adequate documentation of follow-up.
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8 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
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9 We recommended that processes be strengthened to ensure that all informed consents are completed appropriately and that any changes to the consents are discussed with and approved by the patients prior to administration of sedation.
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10 We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo monthly urine drug screenings.
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11 We recommended that processes be strengthened to ensure that discharged MH patients who are on the high risk for suicide list receive follow-up at the required intervals and that compliance be monitored.
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12 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated timely and documented and that compliance be monitored.
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13 We recommended that processes be strengthened to ensure that all patients are notified of biopsy results within the required timeframe and that clinicians document notification in the EHR.
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14 We recommended that processes be strengthened to ensure that clinician notification of critical test results is documented on the required template.
15 We recommended that local policies related to FSBG monitoring and patient management be updated to reflect actual practice.
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16 We recommended that processes be strengthened to ensure that all services complete EHR quality reviews.
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| 12-03073-57 | Combined Assessment Program Review of the Robert J. Dole VA Medical Center, Wichita, Kansas | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs are initiated for all newly hired licensed independent practitioners.
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2 We recommended that processes be strengthened to ensure that all completed ethics consultations are documented in ECWeb.
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3 We recommended that processes be strengthened to ensure that pre-sedation assessment documentation includes all required elements.
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4 We recommended that processes be strengthened to ensure that patients are appropriately monitored during moderate sedation
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5 We recommended that processes be strengthened to ensure that all moderate sedation outpatients are discharged in accordance with VHA requirements.
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6 We recommended that processes be strengthened to ensure that clinical staff in areas where moderate sedation is performed are aware of local policy requirements for identifying correct surgical and invasive procedure sites when the sites cannot be marked.
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7 We recommended that processes be strengthened to ensure that follow-up appointments are consistently scheduled within the timeframes requested by providers.
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8 We recommended that processes be strengthened to ensure that providers document care hand-off in accordance with local policy.
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9 We recommended that processes be strengthened to ensure that interdisciplinary teams develop treatment plans for all polytrauma outpatients who need them and that the plans contain all required elements.
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10 We recommended that the minimum staffing level for a rehabilitation nurse be maintained.
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11 We recommended that processes be strengthened to ensure that service directors develop program-specific competencies and training for all staff assigned to the Polytrauma-TBI Program.
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12 We recommended that processes be strengthened to ensure that oxygen tanks are stored in a manner that distinguishes between empty and full tanks.
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13 We recommended that processes be strengthened to ensure that SCI outpatient clinic employees receive population-specific training.
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14 We recommended that processes be strengthened to ensure that patients are notified of diagnostic test results within the required timeframe and that clinicians document notification.
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15 We recommended that the facility implement the mandated staffing methodology for nursing personnel.
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16 We recommended that processes be strengthened to ensure that all POCT instruments are inspected by biomedical engineering prior to initial use.
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| 12-03399-54 | Healthcare Inspection - Inpatient and Residential Programs for Female Veterans with Mental Health Conditions Related to Military Sexual Trauma | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health review existing VHA policy pertaining to authorization of travel for veterans seeking MST related MH treatment at specialized inpatient/residential programs outside of the facilities where they are enrolled.
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| 12-03072-48 | Combined Assessment Program Review of the VA Central Western Massachusetts Healthcare System, Leeds, Massachusetts | Comprehensive Healthcare Inspection Program | ||
| 12-00580-50 | Community Based Outpatient Clinic Reviews Franklin, WV; Stephens City, VA; Greenbelt, MD; Southeast Washington, DC | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Franklin and Stephens City CBOC clinicians document education of foot care to diabetic patients in CPRS.
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2 We recommended that the Franklin and Stephens City CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
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3 We recommended that the Southeast Washington CBOC clinicians document complete foot screenings for diabetic patients in CPRS.
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4 We recommended that the Greenbelt and Southeast Washington CBOC clinicians document education of foot care to diabetic patients in CPRS.
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5 We recommended that the Greenbelt and Southeast Washington CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
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6 We recommended that the Stephens City CBOC establish a process to ensure that patients with normal mammograms are notified of results within the allotted timeframe and that notification is documented in the medical record.
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7 We recommended that the managers at the Greenbelt and Southeast Washington CBOCs ensure that all mammogram results are documented using the BI-RADS code categories.
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8 We recommended that the Women's Health Program Manager at the Washington DC VAMC ensure that the Greenbelt and Southeast Washington CBOC fee-basis mammography results are received and scanned into CPRS.
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9 We recommended that the Executive Committee of the Medical Staff, Credentialing Committee, grant privileges consistent with the services provided at the Franklin and Stephens City CBOCs.
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10 We recommended that the process is strengthened to ensure that privileges granted to psychologists are provider specific and consistent with the setting in which the services are provided at the Greenbelt CBOC.
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11 We recommended that privacy is maintained at all times during a patient physical examination at the Franklin CBOC.
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12 We recommended that signage is installed at the Franklin CBOC to clearly identify the location of fire extinguishers.
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13 We recommended that fire extinguishers are inspected at the Franklin CBOC and that maintenance and inspection dates are documented in accordance with NFPA Life Safety Code.
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14 We recommended that biohazardous waste containers are stored appropriately and that clean and dirty items are stored in separate locations at the Franklin CBOC.
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15 We recommended that the electrical closet is free of hazardous chemicals at the Stephens City CBOC.
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16 We recommended that fire drills and fire safety inspections are conducted annually at the Greenbelt CBOC.
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17 We recommended that the Facility Director determines, with the assistance of the Regional Counsel, the extent and collectability of the overpayments at the Franklin CBOC.
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18 We recommended that the Facility Director ensures that the contractor provide the invoice in the prescribed format at the Franklin CBOC.
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19 We recommended that the Facility Director ensures that all the performance-reporting provisions of the contract are completed and monitored at the Franklin CBOC.
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20 We recommended that the Facility Director considers adding controls in the invoice validation process, such as preparing a monthly billable roster with VA data at the Franklin CBOC.
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11259