Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 11-00331-160 | Audit of the Community Nursing Home Program | Audit | ||
1 We recommended the Under Secretary for Health ensure Veterans Health Administration community nursing home policies are updated and reissued.
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2 We recommended the Under Secretary for Health conduct a comprehensive national review of nursing homes to ensure veterans are not placed in any nursing homes deemed ineligible by Veterans Health Administration policy, and take appropriate remedial action where necessary.
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3 We recommended the Under Secretary for Health implement a formal oversight and communication process to ensure healthcare facilities comply with Veterans Health Administration nursing home policy and perform proper eligibility reviews.
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4 We recommended the Under Secretary for Health establish a monitoring mechanism to ensure the Office of Geriatrics and Extended Care Strategic Healthcare Group, and healthcare facilities, use the Community Nursing Home Certification Report to monitor the nursing home program and identify high-risk nursing homes.
Closure Date:
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| 13-00026-157 | Community Based Outpatient Clinic Reviews at VA Palo Alto Health Care System, Palo Alto, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that managers ensure that clinicians administer pneumococcal vaccinations when indicated.
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2 We recommended that managers ensure that clinicians document all required pneumococcal and tetanus vaccination administration elements and that compliance is monitored.
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3 We recommended that testing of the panic alarm system is documented at the Monterey CBOC.
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4 We recommended that patients' PII are secured and protected at the Monterey CBOC.
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| 13-00279-156 | Combined Assessment Program Review of the VA Palo Alto Health Care System, Palo Alto, California | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that actions from peer reviews are clearly defined and consistently tracked to completion at the service level.
Closure Date:
2 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
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3 We recommended that processes be strengthened to ensure that the results of proficiency testing and the results of peer reviews when transfusions did not meet criteria are reported to the Transfusion Review Committee.
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4 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect that actions taken in response to identified deficiencies are tracked to closure.
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5 We recommended that processes be strengthened to ensure that sharps containers in the Menlo Park CLC are readily accessible to all staff.
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6 We recommended that processes be strengthened to ensure that medication carts are secured at all times and that compliance be monitored.
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7 We recommended that processes be strengthened to ensure that expired multi-dose vials are removed from medication carts in the CLC.
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8 We recommended that the facility fully implement the nurse staffing methodology.
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9 We recommended that managers initiate protected peer review for the one identified patient and complete any recommended review actions.
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| 12-02503-151 | Administrative Investigation, Misuse of Official Time and Resources and Failure to Properly Supervise, Office of Human Resources and Administration, Washington, DC | Administrative Investigation | ||
1 We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with the Offices of Human Resources (OHR) and General Counsel (OGC) to determine the appropriate administrative action to take against [redacted] and ensure that action is taken.
Closure Date:
2 We recommend that the Acting Assistant Secretary for Human Resources and Administration determine the total salary paid to [redacted] for the 39 days that [redacted] was AWOL from VA or worked for [redacted] while on sick leave and ensure that a bill of collection is issued to [redacted] for that amount, since [redacted] cannot receive pay for the period of time that [redacted] was absent without authorization.
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3 We recommend that the Acting Assistant Secretary for Human Resources and Administration confer with OHR and OGC to determine the appropriate administrative action to take against Mr. Viani and ensure that action is taken.
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| 12-01841-152 | Administrative Investigation, Improper Locality Pay, Service Area Office West and Desert Pacific Healthcare Network, Long Beach, CA | Administrative Investigation | ||
1 We recommend that the SAO West Director ensure that the
employee's personnel records accurately reflect her duty station as San Diego from January [redacted], 2012, to present and that a bill of collection is issued to her for the total amount of improper locality pay given to her.
Closure Date:
2 We recommend that the SAO West Director determine whether the
employee should be permitted to telework, and if so, ensure that Mr. Blanchard and the employee receive annual telework training and complete the proper telework paperwork prior to the employee engaging in any telework.
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3 We recommend that the Director of the Desert Pacific Healthcare Network ensure that [redacted] receives HR training as it relates to duty stations, locality pay, and teleworking.
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| 11-02487-158 | Healthcare Inspection - Evaluation of Cataract Surgeries and Outcomes in VHA Facilities | National Healthcare Review | ||
1 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, monitor and ensure consistent verification and documentation of preoperative intraocular lens implant verification in the electronic health record for all cataract surgeries.
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2 We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure the analysis of OSOD data and dissemination of associated quality improvement processes to VA cataract surgery facilities.
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| 12-03629-139 | Inspection of VA Regional Office Nashville, Tennessee | Review | ||
1 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure claims processing staff input suspense diaries in the electronic record to support scheduling of medical reexaminations.
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2 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure claims processing staff take accurate and timely actions to propose or finalize reductions in benefits.
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3 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure accurate second signature reviews of traumatic brain injury claims decisions.
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4 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure staff update the resource directory and regularly contact and provide outreach to homeless shelters and service providers under the VA Regional Office's jurisdiction.
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5 We recommend the Nashville VA Regional Office Director develop and implement a plan to ensure staff accurately identify and expedite processing and monitoring of all homeless veterans' claims.
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| 13-00275-149 | Combined Assessment Program Review of the Chillicothe VA Medical Center, Chillicothe, Ohio | Comprehensive Healthcare Inspection Program | ||
1 We recommended that processes be strengthened to ensure that FPPEs for newly hired licensed independent practitioners are consistently completed.
Closure Date:
2 We recommended that processes be strengthened to ensure that the CPR Committee reviews each code episode.
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3 We recommended that processes be strengthened to ensure that the quality of entries in the EHR is reviewed.
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4 We recommended that processes be strengthened to ensure that the results of non-VA purchased diagnostic tests are consistently scanned into EHRs.
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5 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 for Inpatient Evaluation Center data, utilization management, outcomes from resuscitation, copy and paste, and blood/transfusion reviews.
Closure Date:
6 We recommended that processes be strengthened to ensure that two transfers of CS from one storage area to another are validated and that compliance be monitored.
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7 We recommended that processes be strengthened to ensure that inspectors sign and initial inspection documents in accordance with local policy.
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8 We recommended that processes be strengthened to ensure that the PCCT includes a dedicated administrative support person.
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9 We recommended that processes be strengthened to ensure that all HPC staff and non-HPC staff receive end-of-life training.
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10 We recommended that processes be strengthened to ensure that the CLC-based hospice program offers bereavement services to patients and families.
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11 We recommended that processes be strengthened to ensure that interdisciplinary care plans for HPC inpatients include all elements required by local policy.
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12 We recommended that processes be strengthened to ensure that the COS reviews HRCP activities at least quarterly.
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13 We recommended that processes be strengthened to ensure that home oxygen program patients are re-evaluated for home oxygen therapy annually after the first year.
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14 We recommended that processes be strengthened to ensure that high-risk home oxygen patients are identified.
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15 We recommended that processes be strengthened to ensure that prescribing clinicians conduct initial and follow-up evaluations of home oxygen program patients.
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16 We recommended that managers initiate internal protected peer review for the three identified patients and complete any recommended review actions.
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| 12-03038-145 | Healthcare Inspection – Excessive Length of Stay and Quality of Care Issues in the Emergency Department, William Jennings Bryan Dorn VA Medical Center, Columbia, SC | Hotline Healthcare Inspection | ||
1 We recommended that the Facility Director identify a reporting structure for Emergency Department Integration Software data and ensure that mandated quarterly reports containing and utilizing Emergency Department Integration Software data are provided.
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2 We recommended that the Facility Director ensure that planned actions to address patient flow (hire additional providers and extend hours for the non-urgent area) are implemented and that patient flow outcomes are monitored.
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3 We recommended that the Facility Director ensure that Emergency Department providers and other clinical and administrative staff receive training on the use of Emergency Department Integration Software delay reasons and that accuracy is monitored.
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| 12-02317-144 | Healthcare Inspection - Improper Conduct During Merit Review Proceedings | Hotline Healthcare Inspection | ||
1 To ensure the integrity of the Merit Review process and the appropriateness of funding Dr. Y's research, we recommend that ORD conduct an Administrative Board of Investigation into Dr. X's actions and their consequent effects on the outcome of the review process, and to take appropriate actions, as indicated.
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2 We recommend that ORD consider making modifications to the review process such as: (a) prohibiting SRG members from attending meetings where a spouse's (or immediate family member's) proposal is scheduled for discussion; (b) not posting reviewers' identities prior to the formal SRG group discussion; (c) blinding proposals so that reviewers cannot easily identify the author; and (d) requesting SRG members specify the proposals they are competent to review, but not asking for preferences or selection of primary, secondary, or tertiary reviewer roles.
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14903