Recommendations
572
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-01059-72 | Better Oversight Needed of Accessibility, Safety, and Cleanliness at Contract Facilities Offering VA Disability Exams | Review | ||
1 Formalize the executive director’s intent by requiring the submission to the OIG of a related plan and documentation of progress on implementing VA’s maintenance of an independent and updated list of contract facilities.
2 Comply with the requirements of the customer satisfaction survey contract to route exam comment cards directly between the survey vendor and veteran.
Closure Date:
3 Develop and implement formal standard operating procedures for the contract exam facility site visits detailing roles, responsibilities, objectives, and monitoring.
Closure Date:
4 Update the Medical Disability Examination Office site visit checklist to include a focus on specific ADA and OSHA criteria required by contracts with exam vendors.
Closure Date:
5 Complete a standardized training plan for staff who conduct site visits at contract exam facilities to include ADA and OSHA compliance.
Closure Date:
6 Ensure the Medical Disability Examination Office is conducting complaint-based contract facility inspections.
Closure Date:
7 Enforce contractual requirements for vendors to conduct inspections and recertify all facilities to ensure ADA and OSHA compliance.
8 Review and analyze all veteran complaints related to exam facilities received through all entities and perform complaint-based site visits or create action plans, as necessary.
Closure Date:
9 Make certain that the Medical Disability Examination Office develops a plan with the vendors to determine if each veteran seeking an exam requires accessibility arrangements prior to scheduling.
Closure Date:
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| 22-03463-60 | Delays Occurred in Some Veterans’ Benefits Claims While Awaiting Decision | Review | ||
1 Implement a plan to strengthen the National Work Queue division’s monitoring of claims awaiting decision at its own location to ensure its rules are operating as intended and make adjustments as needed.
Closure Date:
2 Ensure the Office of Field Operations includes the National Work Queue division’s functioning in its annual internal controls assessment and statement of assurance.
Closure Date:
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| 23-02020-85 | Delays in Community Care Consult Processing and Scheduling at the Martinsburg VA Medical Center in West Virginia | Review | ||
1 Ensure that personal information of veterans who have passed away while waiting for community care consults to be scheduled is only shared with staff who need to know for specific work assignments.
Closure Date:
2 Conduct a strategic business evaluation of the community care department’s workflow processes to determine if there are alternatives that could improve consult processing and scheduling efficiency and timeliness.
Closure Date:
3 Continue to increase specialty provider availability in VA and the community for veterans assigned to the Martinsburg VA medical facility.
Closure Date:
4 Ensure that the performance plan of the chief of community care has standards related to the metrics for community care.
Closure Date:
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| 23-00159-160 | Comprehensive Healthcare Inspection of the VA Maryland Health Care System in Baltimore | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs recommend continued privileges for licensed independent practitioners based on Ongoing Professional Practice Evaluation activities, and the Medical Executive Committee recommends them based on evaluation results.
Closure Date:
2 The Deputy Medical Center Director ensures staff post biohazard signs in applicable areas.
Closure Date:
3 The Associate Director ensures staff keep patient care areas safe and clean.
Closure Date:
4 The Assistant Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.
Closure Date:
5 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a patient’s positive suicide risk screen in all ambulatory care settings.
Closure Date:
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| 23-00112-161 | Comprehensive Healthcare Inspection of the Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs regularly complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures the Clinical Executive Board reviews professional practice evaluation data for licensed independent practitioners.
Closure Date:
3 The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
Closure Date:
4 The Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on mental health inpatient unit sleeping room doors.
Closure Date:
5 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation the same calendar day, when logistically feasible and clinically appropriate, for all ambulatory care patients with a positive suicide risk screen.
Closure Date:
6 The Chief of Staff ensures suicide prevention coordinators conduct, track, and report a minimum of five suicide prevention outreach activities each month.
Closure Date:
7 The Chief of Staff ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
Closure Date:
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| 23-02383-152 | Deficiencies in Documentation of Reusable Medical Device Reprocessing and Failures in VISN 22 Oversight of Sterile Processing Service at the Raymond G. Murphy VAMC in Albuquerque, New Mexico | Hotline Healthcare Inspection | ||
1 The VA Desert Pacific Healthcare Network Director strengthens Sterile Processing Service oversight to ensure timely communication of audit findings with action plan expectations to facility leaders.
Closure Date:
2 The VA Desert Pacific Healthcare Network Director ensures entry of audit results into the Sterile Processing Accountability Tool within the required time frame.
Closure Date:
3 The VA Desert Pacific Healthcare Network Director ensures audit results are shared with the Sterile Processing Advisory Board per Veterans Health Administration requirements.
Closure Date:
4 The VA New Mexico Health Care System Director ensures Sterile Processing Service has a process to communicate all instances when high-level disinfection documentation cannot be located to the associated clinical services when the reusable medical devices was used in patient care.
Closure Date:
5 The VA New Mexico Health Care System Director ensures Sterile Processing Service has a formal process in place to sustain daily quality assurance reviews and monitors compliance.
Closure Date:
6 The VA New Mexico Health Care System Director ensures Sterile Processing Service leaders demonstrate clear communication of Sterile Processing Service staff roles and responsibilities in accordance with Veterans Health Administration High Reliability Organization principles and values.
Closure Date:
7 The VA New Mexico Health Care System Director ensures the facility’s Sterile Processing Service identifies and resolves high-level disinfection documentation errors as they occur, prior to use of associated reusable medical devices on patients.
Closure Date:
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| 23-00121-158 | Comprehensive Healthcare Inspection of the VA Finger Lakes Healthcare System in Bath, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures practitioners from other facilities with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for solo licensed independent practitioners.
Closure Date:
2 The Medical Center Director ensures staff conduct environment of care inspections in non-patient care areas at least once per fiscal year.
Closure Date:
3 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation the same day as a patient’s positive suicide risk screen in ambulatory care settings.
Closure Date:
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| 23-00674-153 | Opportunities Exist to Better Integrate Health-Related Social Needs and Social Determinants of Health into Discharge Assessment and Planning | National Healthcare Review | ||
1 The Under Secretary for Health considers the need for a national policy establishing the inclusion of social determinants of health/health-related social needs into discharge assessment and planning.
Closure Date:
2 The Under Secretary for Health considers the implementation of a standardized electronic health record template, such as the Assessing Circumstances and Offering Resources for Needs tool, that includes the assessment of social determinants of health/health-related social needs of hospitalized patients.
Closure Date:
3 The Under Secretary for Health evaluates barriers to assessing social determinants of health/health-related social needs when patients are discharged from VA medical centers.
Closure Date:
4 The Under Secretary for Health promotes the use of health equity tools across VA medical centers
Closure Date:
5 The Under Secretary for Health promotes the establishment of partnerships of VA medical centers with community resources to address social determinants of health/health-related social needs.
Closure Date:
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| 23-00102-150 | Comprehensive Healthcare Inspection of the VA Eastern Kansas Health Care System in Topeka | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures staff maintain a safe environment by keeping walls in good repair.
Closure Date:
2 The Associate Director ensures staff check over-the-door alarms in the inpatient mental health unit according to the manufacturer’s guidelines.
Closure Date:
3 The Associate Director ensures staff document VA police response times for panic alarm testing in the inpatient mental health unit.
Closure Date:
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| 23-00119-156 | Comprehensive Healthcare Inspection of the Kansas City VA Medical Center in Missouri | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures leaders conduct institutional disclosures for all applicable sentinel events.
Closure Date:
2 The Medical Center Director ensures staff complete environment of care inspections in patient and non-patient care areas at the required frequency.
Closure Date:
3 The Medical Center Director ensures staff cover electrical receptacles in the Inpatient Mental Health Unit common area with metal plates.
Closure Date:
4 The Medical Center Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a patient’s positive suicide risk screen.
Closure Date:
5 The Medical Center Director ensures clinical staff notify the suicide prevention team when patients report suicidal behaviors during Comprehensive Suicide Risk Evaluations.
Closure Date:
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11259