Recommendations
829
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 23-01198-47 | Financial Efficiency Inspection of the VA Memphis Healthcare System in Tennessee | Financial Inspection | ||
1 Ensure that healthcare system finance office staff are made aware of all VA financial policy requirements in the review and management of inactive open obligations and deobligate any identified excess funds.
Closure Date:
2 Ensure cardholders comply with VA financial policy record retention requirements.
Closure Date:
3 Establish controls to confirm approving officials and purchase cardholders review purchases for VA policy compliance and ensure contracting is used when it is in the best interest of the government.
Closure Date:
4 Establish local processes and procedures to ensure the routine scanning of inventory items, as well as monitoring of all inventory data, so that performance measures are maintained.
Closure Date:
5 Ensure supply chain managers implement a plan to train staff to promote the standardization of supply chain duties and to correct data validity issues within inventory systems.
Closure Date:
6 Ensure the chief of supply chain services conducts and documents quarterly physical inventory memoranda of “A” classified items in accordance with Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
7 Ensure the chief supply chain officer reviews the edit access list for the facility item master file, and a process is put in place to document this review, as required in the Veterans Health Administration’s Directive 1761, Supply Chain Management Operations.
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8 Develop a plan to align inventory management practices, such as ABC inventory analysis methodology, with Veterans Health Administration policy.
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9 Establish processes to ensure compliance with the Veterans Health Administration directive to complete the B09 reconciliation process.
Closure Date:
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| 23-00011-73 | Comprehensive Healthcare Inspection of the Samuel S. Stratton VA Medical Center in Albany, New York | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs use service-specific criteria in the professional practice evaluations of licensed independent practitioners.
Closure Date:
2 The Chief of Staff ensures practitioners with equivalent specialized training and similar privileges complete professional practice evaluations.
Closure Date:
3 The Executive Medical Center Director ensures the Comprehensive Environment of Care Coordinator schedules, and staff complete and document, environment of care inspections at the required frequency.
Closure Date:
4 The Executive Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit.
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5 The Executive Medical Center Director ensures appropriate personnel install over-the-door alarms for sleeping room doors in the mental health inpatient unit.
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6 The Executive Medical Center Director ensures staff follow the manufacturer’s recommendations for testing over-the-door alarms on sleeping room doors in the mental health inpatient unit.
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7 The Executive Medical Center Director ensures staff maintain a safe environment in the mental health inpatient unit.
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8 The Executive Medical Center Director ensures staff keep patient care areas safe and clean.
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9 The Chief of Staff ensures designated staff complete the Comprehensive Suicide Risk Evaluation on the same calendar day as a positive suicide risk screen, when logistically feasible and clinically appropriate, for all ambulatory care patients.
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10 The Chief of Staff ensures the Suicide Prevention Coordinator conducts, tracks, and reports a minimum of five suicide prevention outreach activities monthly.
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| 21-03255-02 | Noncompliance with Contractor Employee Vetting Requirements Exposes VA to Risk | Audit | ||
1 Mediate the two offices’ collaboration to develop and publish updates to the personnel security policies and procedures for vetting contractor employees to include appropriate roles and responsibilities; standard contract language to communicate the requirements for vetting contractor employees, including whether a fingerprint check or background investigation is required, that can be used across the department; and a requirement that the VA organization requesting a contract provide the position designation record in the acquisition package submitted to the contracting office.
2 Perform and document compliance inspections of the procedures for vetting contractor employees and the issuance of VA identification credentials at medical facilities supported by Network Contracting Office 23, including the St. Cloud VA Medical Center.
Closure Date:
3 Update and publish the Veterans Affairs Acquisition Regulation and Veterans Affairs Acquisition Manual to direct the department’s acquisition professionals to the correct guidance for vetting contractor employees, which should include VA’s personnel security and suitability program policy.
4 Update and publish or rescind Acquisition Policy Flash 16-13, “Use of VA Handbook 6500.6, Appendix A, Checklist for Information Security in VA Service Acquisitions,” to ensure VA acquisition professionals understand that VA Handbook 6500.6 is not the only personnel security policy they must comply with.
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5 Update and publish VA Handbook 6500.6, Contract Security, in collaboration with the Office of Acquisition, Logistics, and Construction and the Office of Human Resources and Administration/Operations, Security, and Preparedness, including retitling it to better correspond to its content and removing any personnel security steps that should only be discussed in VA personnel security and suitability program policies.
6 Review the actions of the officials responsible for planning, awarding, and administering contract 36C26320A0021, which included vetting procedures that did not comply with federal or VA policies, and take administrative action if appropriate.
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| 22-04134-63 | Comprehensive Healthcare Inspection of the Clement J. Zablocki VA Medical Center in Milwaukee, Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff keep all areas clean and safe.
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2 The Director ensures staff keep the medical center well maintained.
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3 The Chief of Pharmacy Services limits medication access to approved staff members.
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4 The Director ensures staff store sterile supplies in temperature- and humidity-controlled storage rooms.
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5 The Director ensures providers complete the Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.
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6 The Director ensures providers notify the suicide prevention team of patients who report suicidal behaviors during the Comprehensive Suicide Risk Evaluation.
Closure Date:
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| 23-00005-62 | Comprehensive Healthcare Inspection of the Ralph H. Johnson VA Medical Center in Charleston, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Medical Center Director ensures staff complete root cause analyses for all patient safety events assigned an actual or potential safety assessment code score of 3.
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2 The Veterans Integrated Service Network Director ensures external practitioners with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations for practitioners in “two-deep” services or specialties.
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3 The Medical Center Director ensures the Safety and Occupational Health Specialist or designee tracks environment of care inspection deficiencies until they are resolved.
Closure Date:
4 The Medical Center Director ensures staff document police response times to panic alarm testing in the mental health inpatient unit at least quarterly.
Closure Date:
5 The Medical Center Director ensures the Supervisory Suicide Prevention Coordinator reports suicide-related events monthly to mental health leaders and quality management staff.
Closure Date:
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| 22-02975-70 | Chief of Staff’s Provision of Care Without Privileges, Quality of Care Deficiencies, and Leaders’ Failures at the Montana VA Health Care System in Helena | Hotline Healthcare Inspection | ||
1 The Montana VA Health Care System Medical Center Director ensures that all providers, including the Chief of Staff, practice within their approved privileges.
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2 The Under Secretary for Health ensures review of Veterans Health Administration maternity care directives to determine if more specific guidance on the limitations of pregnancy care at VA facilities is necessary to ensure that pregnant patients receive maternity care according to evidence-based practice standards, and ensures guidance is updated as warranted.
Closure Date:
3 The Montana VA Health Care System Medical Center Director ensures adherence to Veterans Health Administration and facility policies for pregnancy care.
Closure Date:
4 The Montana VA Health Care System Medical Center Director ensures subject matter expert review of endometrial ablation procedures performed by the facility Chief of Staff to determine whether standards of care were followed for clinical indications, patient selection, and preoperative evaluation for patients who underwent endometrial ablation, and determine whether clinical disclosures or additional patient follow-up is indicated.
Closure Date:
5 The Rocky Mountain Network Director ensures processes are in place to support facilities’ external review process for ongoing professional practice evaluations in cases requiring external review by Veterans Health Administration policy and monitors compliance.
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6 The Montana VA Health Care System Medical Center Director ensures adherence to all VHA and facility policies pertaining to privileging and re-privileging of providers including the Chief of Staff.
Closure Date:
7 The Montana VA Health Care System Medical Center Director conducts a comprehensive review of the facility ongoing professional practice evaluation processes to ensure compliance with Veterans Health Administration and facility policy, and takes action as warranted.
Closure Date:
8 The Rocky Mountain Network Director ensures a process is in place to monitor for timely completion of administrative actions for members of facility executive leadership team when appropriate, identifies noncompliance, and takes action as warranted.
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9 The Rocky Mountain Network Director conducts a review of the state licensing board reporting processes at the facility to ensure compliance with Veterans Health Administration policy, identifies noncompliance, and takes action as warranted.
Closure Date:
10 The Montana VA Health Care System Medical Center Director considers subject matter expert findings from the retrospective review of care provided by the Chief of Staff, determines whether clinical or institutional disclosures or additional patient follow-up is indicated, and takes action as warranted.
Closure Date:
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| 23-01325-59 | Discontinued Consults Led to Patient Care Delays at the Oklahoma City VA Medical Center in Oklahoma | Hotline Healthcare Inspection | ||
1 The Oklahoma City VA Health Care System Director, in conjunction with Behavioral Health Service leaders, reviews the community care consult management and appointment scheduling processes, identifies deficiencies, and takes action as warranted.
Closure Date:
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| 23-00009-57 | Comprehensive Healthcare Inspection of the Columbia VA Health Care System in South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff have written procedures for responding to utility system disruptions.
Closure Date:
2 The Director ensures staff identify, minimize, or eliminate safety and security risks in the physical environment.
Closure Date:
3 The Director 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:
4 The Director 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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| 22-00057-54 | Comprehensive Healthcare Inspection of Veterans Integrated Service Network 22: VA Desert Pacific Healthcare Network in Long Beach, California | Comprehensive Healthcare Inspection Program | ||
1 The Network Director determines the reasons for noncompliance and ensures the Patient Safety Officer collects, analyzes, and acts on peer review summary data.
Closure Date:
2 The Chief Medical Officer determines any additional reasons for noncompliance and reviews the credentials file and makes a recommendation on continuing the appointment process for physicians with a potentially disqualifying licensure action.
Closure Date:
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| 22-04131-49 | Delay of a Patient’s Prostate Cancer Diagnosis, Failure to Ensure Quality Urologic Care, and Concerns with Lung Cancer Screening at the Central Texas Veterans Health Care System in Temple | Hotline Healthcare Inspection | ||
1 The Central Texas VA Health Care System Director reviews the care provided to the patient by Nurse Practitioner 1 and Nurse Practitioner 2 and takes action as warranted.
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2 The Central Texas VA Health Care System Director reviews the care provided by Nurse Practitioner 1 and Nurse Practitioner 2 as licensed independent practitioners to other urology patients, and takes action as warranted.
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3 The Central Texas VA Health Care System Director reviews the privileging and professional practice evaluation processes and performance indicators for nurse practitioners granted full practice authority in specialty care clinics to ensure compliance with current Veterans Health Administration policy and quality of care.
4 The Central Texas VA Health Care System Director ensures that facility leaders communicate expectations related to low-dose computed tomography scans for lung cancer screening to facility primary care providers.
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11259