Recommendations
933
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-03909-19 | VA Should Enhance Its Oversight to Improve the Accessibility of Websites and Information Technology Systems for Individuals with Disabilities | Audit | ||
1 Develop and implement a strategy with milestones for identifying all VA websites, confirm their inclusion in VA’s Web Registry as the current system designated by policy, and certify the accuracy of entries annually or as changes occur.
2 Establish a mechanism for web communication offices across VA to enforce the implementation of VA Handbook 6102 related to Section 508 compliance.
3 Coordinate with VA under secretaries and other assistant secretaries to ensure system owners are educated on VA Directive 6221 and its accompanying handbook requirements to request accessibility audits.
4 Institute a mechanism to ensure information technology system accessibility designations are accurate in the VA Systems Inventory.
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5 Update, recertify, and republish VA Directives 6221 (accessible information and communications technology) and 6404 (systems inventory).
6 Update, recertify, and publish VA Directive 6515 (use of web-based collaboration technologies).
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| 23-00777-52 | Care Deficiencies and Leaders’ Inadequate Reviews of a Patient Who Died at the Lt. Col. Luke Weathers, Jr. VA Medical Center in Memphis, Tennessee | Hotline Healthcare Inspection | ||
1 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures Nursing Service staff comply with the cardiac telemetry monitoring policy.
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2 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures the medical floor charge nurses create nursing assignments and communicate this information to the telemetry technician and monitors for compliance.
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3 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that Intensive Care Unit Service physicians document and complete written responses to critical care consults as required and monitors for compliance.
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4 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director ensures that the Quality Management and Performance Improvement Service conduct administrative reviews and root cause analyses in accordance with Veterans Affairs and Veterans Health Administration policy and monitors for compliance.
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5 The Lt. Col. Luke Weathers, Jr. VA Medical Center Director consider completion of another root cause analysis to ensure additional system vulnerabilities that may have contributed to this patient event are identified and action plans completed, as applicable, to prevent reoccurrence of similar patient events.
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| 22-04132-48 | Comprehensive Healthcare Inspection of the Tomah VA Medical Center in Wisconsin | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures service chiefs monitor licensed independent practitioners’ performance by conducting Ongoing Professional Practice Evaluations on a regular basis.
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2 The Medical Center Director ensures the Safety and Occupational Health Specialist or designee schedules and ensures staff complete and document environment of care inspections at the required frequency.
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3 The Medical Center Director ensures staff monitor and document VA police response times to panic alarm testing in the Acute Inpatient Mental Health Unit at least quarterly.
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4 The Medical Center Director ensures the Suicide Prevention Coordinator conducts a minimum of five outreach activities each month.
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5 The Medical Center Director ensures the Suicide Prevention Coordinator reports suicide-related events monthly to mental health and quality management leaders.
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| 23-00093-51 | Comprehensive Healthcare Inspection of the Wilmington VA Medical Center in Delaware | Comprehensive Healthcare Inspection Program | ||
1 The Director ensures staff track deficiencies identified during comprehensive environment of care inspections through resolution.
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2 The Director ensures staff maintain a safe and clean environment.
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| 21-01488-44 | Veterans Health Administration Needs More Written Guidance to Better Manage Inpatient Management of Alcohol Withdrawal | National Healthcare Review | ||
1 The Under Secretary for Health consider identifying a national program office to be responsible for oversight of alcohol withdrawal management across inpatient settings.
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2 The Under Secretary for Health ensures the identified national program office responsible for oversight of alcohol withdrawal management consider requiring the development and implementation of written guidance for the management of alcohol withdrawal across all inpatient settings, to include: (a) expectations for determining alcohol withdrawal severity, level of care, and when transfer of care is indicated; (b) expected actions of nurses to communicate with prescribers based on patients’ changes in symptoms or alcohol withdrawal severity and when that communication should be followed by a prescribers face-to-face evaluation of a patient; (c) expectations for the evaluation of co-occurring conditions, expert consultation, and pharmacotherapy approaches; and (d) expectations for the collection and monitoring of outcome data for inpatient management of alcohol withdrawal at the national and healthcare system level.
3 The Under Secretary for Health consider the implementation of training for inpatient staff on the administration of standardized alcohol withdrawal severity scales.
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| 22-02294-42 | Deficiencies in the Community Care Network Credentialing Process of a Former VA Surgeon and Veterans Health Administration Oversight Failures | Hotline Healthcare Inspection | ||
1 The Under Secretary for Health initiates a review of the surgeon’s eligibility to participate in VA’s Community Care Network given Optum’s lack of documentation of their review of the surgeon’s credentialing file and takes action, as indicated.
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2 The Under Secretary for Health reviews community care network contracts and considers modifying contracts to ensure that voluntary relinquishments and surrenders of licenses for disciplinary reasons are disqualifying for participation in VA’s Community Care Network consistent with the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act.
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3 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures Optum’s sufficient review and discussion of community care network providers’adverse credentialing files and monitors for compliance.
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4 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum documents community care network provider credentialing decisions asrequired and monitors for compliance.
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5 The Office of Integrated Veteran Care Executive Director, Integrated External Networks ensures that Optum complies with community care contract provisions to provide Integrated Veteran Care with accreditation and credentialing documentation in accordance with federal privacy laws and VA’s community care network contract.
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6 The Office of Integrated Veteran Care Executive Director, Integrated External Networks verifies that providers identified on the 2021 Government Accountability Office list are eligible to provide care in the VA Community Care Network.
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7 The VA Heartland Network Director initiates a review of all community care provided by the surgeon.
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8 The VA Marion Health Care System Director ensures primary care and patient safety staff receive education on their responsibility for Joint Patient Safety Reporting and follow-up of patient safety events related to community care, and monitors compliance with patient safety event reporting and follow-up.
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| 23-01690-31 | Without Effective Controls, Public Disability Benefits Questionnaires Continue to Pose a Significant Risk of Fraud to VA | Review | ||
1 Direct the Office of Financial Management to continue to develop a system for digitally capturing, analyzing, and monitoring public questionnaires to identify inauthentic or potentially fraudulent questionnaires and work with the Compensation Service to develop policies for reviewing and remediating any such public questionnaires identified.
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2 Have the Medical Disability Examination Office update the examiner certification and signature section found in public questionnaires to include that the form is being completed under the penalty of perjury and to ask examiners to list any organizations that requested they complete the examinations on the claimant’s behalf.
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3 Instruct the Compensation Service to provide claims processors guidance in the procedures manual on how to identify a potentially fraudulent public questionnaire, and provide the steps they should take when they suspect that a public questionnaire may be inauthentic or potentially fraudulent.
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4 Require the Compensation Service to inform claims processors as part of the public questionnaire review process that they have a duty to review and weigh all the evidence of record, including public questionnaires, and that they have the responsibility to assign low or no probative value if they have reason to suspect that the public questionnaire is inauthentic or potentially fraudulent.
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5 Direct the Veterans Benefits Administration to develop and provide training on authentication and fraud, including training related to public questionnaires, to provide claims processors with the knowledge to identify inauthentic or potentially fraudulent public questionnaires, and include what steps claims processors should take when they make that determination.
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| 23-00007-45 | Comprehensive Healthcare Inspection of the Miami VA Healthcare System in Florida | Comprehensive Healthcare Inspection Program | ||
1 The Executive Director ensures staff complete peer reviews for unanticipated deaths occurring within 24 hours of admission.
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2 The Chief of Staff ensures service chiefs complete Ongoing Professional Practice Evaluations for licensed independent practitioners.
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| 22-03165-46 | Comprehensive Healthcare Inspection of the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers with equivalent specialized training and similar privileges complete Ongoing Professional Practice Evaluations of licensed independent practitioners.
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2 The Chief of Staff ensures service chiefs include service-specific criteria in the Ongoing Professional Practice Evaluations of licensed independent practitioners.
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3 The Associate Director ensures managers maintain a safe and clean environment throughout the medical center.
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4 The Chief of Staff ensures providers complete the Comprehensive Suicide Risk Evaluation on the same day as a positive suicide risk screen when it is clinically appropriate.
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| 23-00004-37 | Comprehensive Healthcare Inspection of the W.G. (Bill) Hefner VA Medical Center in Salisbury, North Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures providers complete a Comprehensive Suicide Risk Evaluation following a positive suicide risk screen.
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2 The Chief of Staff ensures clinical staff notify the suicide prevention team if patients report suicidal or other self-directed violent behaviors that occurred in the 12 months preceding the Comprehensive Suicide Risk Evaluation.
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3 The Chief of Staff ensures leaders appoint one full-time suicide prevention coordinator to each community-based outpatient clinic that serves at least 10,000 unique veterans annually.
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4 The Chief of Staff ensures the Suicide Prevention Program Manager reports suicide-related events monthly to mental health leaders and quality management staff.
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11259