Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 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.
Closure Date:
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 | ||
1 We recommended that processes be strengthened to ensure that EOC Committee minutes reflect sufficient analysis and follow-up of EOC inspection findings and track identified deficiencies to resolution.
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2 We recommended that processes be strengthened to ensure that patient care areas are clean and that compliance be monitored.
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3 We recommended that processes be strengthened to ensure that the hazardous materials inventory is current.
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4 We recommended that processes be strengthened to ensure that hazard assessments are completed in the dental laboratory and the ED and that emergency eyewash stations are added if needed.
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5 We recommended that processes be strengthened to ensure that required SCI outpatient clinic staff are assigned and receive SCI-specific training and that compliance with training requirements be monitored.
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6 We recommended that processes be strengthened to ensure that patients are notified of positive CRC screening test results within the required timeframe and that clinicians document notification.
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7 We recommended that processes be strengthened to ensure that responsible clinicians either develop follow-up plans or document that no follow-up is indicated within the required timeframe.
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8 We recommended that processes be strengthened to ensure that patients with positive CRC screening test results receive diagnostic testing within the required timeframe and that the facility evaluate the five cases to determine what further actions may be warranted.
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9 We recommended that processes be strengthened to ensure that medications ordered at discharge match those listed on patient discharge instructions.
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10 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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11 We recommended that processes be strengthened to ensure that discharge summaries include discharge medications.
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12 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
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13 We recommended that processes be strengthened to ensure that all 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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14 We recommended that processes be strengthened to ensure that attempts to follow up with patients who fail to keep their MH appointments are initiated and documented and that compliance be monitored.
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15 We recommended that processes be strengthened to ensure that the designated clinical service respond to consultation requests for TBI comprehensive evaluations within the required timeframe.
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16 We recommended that processes be strengthened to ensure that all patients with positive TBI screening results receive a comprehensive evaluation within the required timeframe.
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17 We recommended that the facility comply with polytrauma training requirements.
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18 We recommended that senior managers discuss the data from the Inpatient Evaluation Center at a senior-level committee and document the discussion in the committee's meeting minutes.
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19 We recommended that processes be strengthened to ensure that FPPEs are completed for all newly hired licensed independent practitioners and that results are consistently reported to the Medical Executive Committee.
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20 We recommended that processes be strengthened to ensure that clinical service EHR quality reviews are completed and results forwarded to the EHR Committee and that the EHR Committee provides consistent oversight, coordination, and evaluation of EHR quality reviews.
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21 We recommended that processes be strengthened to ensure that the copy and paste functions are monitored.
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22 We recommended that processes be strengthened to ensure that staff complete all actions required in response to critical test results.
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23 We recommended that processes be strengthened to ensure that providers sign all pre-sedation assessments completed by nursing staff.
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| 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.
Closure Date:
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.
Closure Date:
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.
Closure Date:
16 We recommended that processes be strengthened to ensure that all services complete EHR quality reviews.
Closure Date:
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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.
Closure Date:
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 | ||
1 We recommended that processes be strengthened to ensure that at least two preventive ethics improvement cycles are completed each FY.
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2 We recommended that processes be strengthened to ensure that the EHR committee provides consistent oversight and coordination of EHR quality reviews and that quality reviews are completed, analyzed, and trended for all services, including long-term care.
Closure Date:
3 We recommended that a rehabilitation nurse be available for the polytrauma program.
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4 We recommended that processes be strengthened to ensure that all patients in opioid dependence treatment undergo urine drug screenings with the frequency required by local policy.
Closure Date:
5 We recommended that processes be strengthened to ensure that all discharged MH patients who are not on the high risk for suicide list receive follow-up within the specified timeframes and that compliance be monitored.
Closure Date:
6 We recommended that processes be strengthened to ensure that all discharged MH patients who are on the high risk for suicide list receive follow-up evaluations at the required intervals and that compliance be monitored.
Closure Date:
7 We recommended that processes be strengthened to ensure that employees who perform glucose POCT have their competency assessed at the required intervals.
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8 We recommended that processes be strengthened to ensure that staff complete and document the actions required in response to critical test results.
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9 We recommended that processes be strengthened to ensure that Clinical Engineering staff inspect, approve, and label glucose meters in accordance with local policy.
Closure Date:
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| 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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| 12-03858-46 | Healthcare Inspection – Alleged Resident Abuse and Abuse Reporting Irregularities at the Pueblo Community Living Center, VA Eastern Colorado Healthcare System, Denver, Colorado | Hotline Healthcare Inspection | ||
1 We recommended that the system Director ensure all Associate Chiefs of Nursing and Community Living Center staff receive retraining on the requirements for reporting allegations of abuse.
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2 We recommended that the system Director ensures procedures to report, log, track, trend, and analyze injuries of unknown origin at the Community Living Center are developed.
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| 12-02277-49 | Healthcare Inspection - Clinical and Administrative Allegations Involving Surgical Service, Carl Vinson VA Medical Center, Dublin, GA | Hotline Healthcare Inspection | ||
1 We recommended that the facility Director ensure that provider reprivileging processes be conducted in accordance with VHA guidelines.
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2 We recommended that the facility Director ensure the OOPRC collects and analyzes aggregated surgical complication data to identify trends and patterns, and takes appropriate corrective actions when indicated.
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| 12-00581-27 | Community Based Outpatient Clinic Reviews Minden (Carson Valley), NV; Auburn (Sierra Foothills), Chula Vista, and Escondido, CA | Comprehensive Healthcare Inspection Program | ||
1 We recommended that the Facility Director ensure that foot screening and patient referral guidelines are established in accordance with VHA policy.
Closure Date:
2 We recommended that the Sierra Foothills CBOC clinicians document foot care education to diabetic patients in CPRS.
Closure Date:
3 We recommended that the Carson Valley CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
Closure Date:
4 We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
5 We recommended that the Carson Valley and Sierra Foothills CBOC clinicians document that therapeutic footwear or orthotics is prescribed to diabetic patients identified at high risk for extremity ulcers and amputation.
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6 We recommended that the Chula Vista and Escondido CBOC clinicians document foot care education to diabetic patients in CPRS.
Closure Date:
7 We recommended that the Chula Vista and Escondido CBOC clinicians document a complete foot screening for diabetic patients in CPRS.
Closure Date:
8 We recommended that the Chula Vista and Escondido CBOC clinicians document a risk level for diabetic patients in CPRS in accordance with VHA policy.
Closure Date:
9 We recommended that the Carson Valley CBOC establish a process to ensure that patients with normal mammogram results are notified of results within the allotted timeframe and that notification is documented in the medical record.
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10 We recommended that the Women¿s Health Liaison at the Chula Vista CBOC attend the Women¿s Health Committee meetings and routinely collaborate with the Women Veterans Program Manager.
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11 We recommended that the privileges granted to providers are consistent with the services provided at the Chula Vista CBOC and that privileges are setting specific at Chula Vista and Escondido CBOCs.
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12 We recommended that OPPE data be maintained in all providers¿ profiles at the Escondido CBOC.
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13 We recommended that managers collect and analyze data for hand hygiene at the Carson Valley and Sierra Foothills CBOCs.
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14 We recommended that the VISN and Facility Directors ensure that the deficiencies at the Escondido CBOC are addressed and corrected to ensure compliance with the ADA requirements.
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15 We recommended that the Chula Vista CBOC implement a process to ensure that patient PII is protected and secured.
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16 We recommended that the Network Contracting Office, in conjunction with VISN and Facility Directors, award a competitive long-term contract and to ensure that future acquisitions allow for adequate planning time to avoid the need for ICA.
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17 We recommended that the Service Area Office (SAO) West Director and MSO Directors ensure that the use of ICA complies with VA directives.
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18 We recommended that the SAO West Director and Network Contract Manager ensure appropriate oversight and enforcement of VA directives before an ICA is approved and a contract is signed.
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19 We recommended that the SAO West Director and Network Contract Manager ensure that contracting officers are held accountable for noncompliance with VA directives.
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20 We recommended that the Facility Director and Network Contract Manager confer with Regional Counsel to determine the amount and collectability of all overpayments.
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14903