Recommendations
1367
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 22-04099-153 | Review of VISN 10 and Facility Leaders’ Response to Recommendations from a VHA Office of the Medical Inspector Report, John D. Dingell VA Medical Center in Detroit, Michigan | Hotline Healthcare Inspection | ||
1 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director evaluates and ensures all Veterans Integrated Service Network 10 facilities comply with Veterans Health Administration requirements regarding resident supervision, specifically related to post-graduate year one on-site direct supervision.
2 The John D. Dingell VA Medical Center Director reviews the March 2023 National Surgery Office program review as referenced in the Office of the Medical Inspector report and ensures a comprehensive and sustainable response to the recommendations noted in the National Surgery Office memorandum.
Closure Date:
3 The John D. Dingell VA Medical Center Director and facility leaders meet all Veterans Health Administration requirements for National Practitioner Data Bank and State Licensing Board reporting for healthcare providers that meet reporting criteria.
Closure Date:
4 The John D. Dingell VA Medical Center Director ensures the chief of surgery facilitates and provides oversight of morbidity and mortality conferences.
Closure Date:
5 The John D. Dingell VA Medical Center Director ensures that initial level 3 peer review results of Peer Review Committee members’ cases are reassessed by another neutral VA facility Peer Review Committee for final level determination.
Closure Date:
6 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network academic affiliations officer maintains awareness of and performs assigned roles and responsibilities per Veterans Health Administration requirements.
Closure Date:
7 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director ensures the Veterans Integrated Service Network surgical workgroup reviews applicable Veterans Health Administration policies, and documents discussion and action plans to reflect facilities’ compliance with Veterans Health Administration policy and surgical complexity level.
Closure Date:
8 The VA Healthcare System Serving Ohio, Indiana and Michigan Network Director provides continued oversight and structured support to executive and service line leaders during key leader transitions, and monitors actions taken to ensure completion of action plans.
Closure Date:
9 The John D. Dingell VA Medical Center Director reviews organizational communication channels and ensures consistency with Veterans Health Administration High Reliability Organization goals and considers the use of Veterans Health Administration resources such as the Veterans Health Administration National Center for Organization Development.
Closure Date:
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| 22-04104-112 | Inspection of Information Security at the Northern Arizona VA Healthcare System | Information Security Inspection | ||
1 Implement a more effective vulnerability management program to address security deficiencies identified during the inspection.
Closure Date:
2 Ensure vulnerabilities are remediated within established time frames.
3 Implement more effective configuration control processes to ensure network devices maintain vendor support.
Closure Date:
4 Ensure the unmanaged database completes the transition to the VA Enterprise Cloud where it can be managed and have security baselines applied.
Closure Date:
5 Implement an improved inventory process to ensure that all connected devices used to support VA programs and operations are documented in the Enterprise Mission Assurance Support Service.
Closure Date:
6 Ensure network infrastructure equipment is properly installed.
Closure Date:
7 Ensure physical access controls are implemented for communication rooms.
Closure Date:
8 Ensure a video surveillance system is operational and monitored for the data center.
Closure Date:
9 Ensure communication rooms with infrastructure equipment have adequate environmental controls.
Closure Date:
10 Ensure communication rooms with infrastructure equipment have fire-detection and suppression systems.
Closure Date:
11 Ensure water detection sensors are implemented in the data center.
Closure Date:
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| 18-00613-275 | Comprehensive Healthcare Inspection Program Review of the Veterans Health Care System of the Ozarks, Fayetteville, Arkansas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that an interdisciplinary Facility group review Utilization Management data and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that Service Chiefs consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
3 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
4 The Facility Director ensures that the duties of the controlled substance coordinator and alternate controlled substance coordinator are included in the employees’ position descriptions or functional statements and monitors compliance.
Closure Date:
5 The Facility Director ensures controlled substance inspectors complete controlled substance order verifications and monitors compliance.
Closure Date:
6 The Chief of Staff ensures staff link the mammography results to the radiology order and monitors compliance.
Closure Date:
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| 17-02484-189 | Alleged Mismanagement of Inpatient Care at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas | Hotline Healthcare Inspection | ||
1 The System Director ensures provider privileges are facility-specific as required by Veterans Health Administration Handbook 1100.19, Credentialing and Privileging, October 15, 2012.
Closure Date:
2 The System Director ensures the System’s Bylaws and Rules of the Medical Staff are updated to reflect compatibility and compliance with 38 CFR 17.415, Full Practice Authority for Advance Practice Registered Nurses.
Closure Date:
3 The System Director ensures the Facility meets the requirements for physician staffing for inpatient coverage, pre-operative risk and anesthesia assessments, and anesthesia services in-house coverage as required by Veterans Health Administration Directive 2010-018, Facility Infrastructure Requirements to Perform Standard, Intermediate, or Complex Surgical Procedures, May 6, 2010.
Closure Date:
4 The System Director reviews the timeliness of specialty care consults and ensures that specialty consults are provided timely as required by Veterans Health Administration policy, including the use of service/care coordination agreements as necessary to define time frames.
Closure Date:
5 The System Director ensures the Facility provides a list to the Emergency Department and inpatient staff of appropriate on-call social work and mental health staff, as well as specialty physicians, including radiologists, as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
Closure Date:
6 The System Director ensures the Facility provides and monitors the availability and timely response of specialty consultants and ultrasound services in the Emergency Department as required by Veterans Health Administration Directive 1101.05 (2), Emergency Department, September 2, 2016, (amended March 7, 2017).
Closure Date:
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| 18-01693-196 | OIG Determination of Veterans Health Administration’s Occupational Staffing Shortages FY 2018 | National Healthcare Review | ||
1 The Under Secretary for Health refines and formalizes VHA’s position categorization of individuals (clinical and nonclinical) who are necessary to VHA’s mission of delivering health care by looking at various dimensions of each occupation, including staff skill set and function, enabling identification of positions based on the specific role a person would fill.
Closure Date:
2 The Under Secretary for Health ensures the consistent implementation and use of the position categorization approach across all facilities.
Closure Date:
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| 18-00611-180 | Comprehensive Healthcare Inspection Program Review of the Phoenix VA Health Care System, Phoenix, Arizona | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures Physician Utilization Management Advisors consistently document their decisions in the National Utilization Management Integration database and monitors the advisors’ compliance.
Closure Date:
2 The Facility Director ensures all patient incidents are entered into WebSPOT and monitors compliance.
Closure Date:
3 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors team members’ compliance.
Closure Date:
4 The Deputy Director and Associate Director ensure personal protective equipment is readily accessible and monitor compliance.
Closure Date:
5 The Associate Director ensures that a clean environment is maintained throughout the Facility and monitors compliance.
Closure Date:
6 The Associate Director requires Nutrition and Food Service managers ensure garbage receptacles are stored separately from food preparation areas and properly covered with tight-fitting lids and monitors managers’ compliance.
Closure Date:
7 The Associate Director requires Nutrition and Food Services managers ensure all food items are properly labeled with expiration dates, as appropriate, and monitors managers’ compliance.
Closure Date:
8 The Associate Director requires Nutrition and Food Services managers ensure temperature monitoring occurs in the dry food storage area and monitors managers’ compliance.
Closure Date:
9 The Facility Director ensures that Controlled Substances Inspectors complete routine monthly controlled substances inspections and monitors compliance.
Closure Date:
10 The Facility Director ensures that controlled substances inspections are randomly performed to ensure the element of surprise and monitors compliance.
Closure Date:
11 The Facility Director ensures that reconciliation of controlled substances returns to pharmacy stock is performed during controlled substances inspections and monitors compliance.
Closure Date:
12 The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
13 The Chief of Staff ensures that geriatric evaluation providers complete a medical evaluation of patients admitted to the program and monitors providers’ compliance.
Closure Date:
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| 16-02940-183 | Colorectal Cancer Screening, Timely Colonoscopies, and Physician Coverage in the Intensive Care Unit at the James H. Quillen VA Medical Center, Mountain Home, Tennessee | Hotline Healthcare Inspection | ||
1 The Veterans Integrated Service Network 9 Director ensures that clinical reviews are completed on the patients discussed in this report to determine whether delays adversely affected patients’ clinical care, notifies patients of lapses in care as needed, and/or takes other action as appropriate.
Closure Date:
2 The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track and recall patients who require surveillance colonoscopies.
Closure Date:
3 The James H. Quillen VA Medical Center Director improves and monitors mechanisms to track patients for whom a diagnostic colonoscopy after a positive fecal immunochemical test is indicated as required by Veterans Health Administration and James H. Quillen VA Medical Center policy.
Closure Date:
4 The James H. Quillen VA Medical Center Director improves efforts to ensure non-VA colonoscopy reports are available for viewing in patients’ VA electronic health records.
Closure Date:
5 The James H. Quillen VA Medical Center Director ensures that processes are in place to monitor providers’ compliance with Veterans Health Administration Colorectal Cancer Screening policy including the referral of the patient for a diagnostic colonoscopy after a positive fecal immunochemical test rather than a repeat fecal immunochemical test.
Closure Date:
6 The James H. Quillen VA Medical Center Director takes action to identify patients who submitted fecal immunochemical test kits that could not be processed and notifies these patients of a need to re-submit fecal immunochemical test specimens.
Closure Date:
7 The James H. Quillen VA Medical Center Director ensures that processes are strengthened to track and monitor the distribution of fecal immunochemical test kits to patients.
Closure Date:
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| 17-05398-172 | Comprehensive Healthcare Inspection Program Review of the Cincinnati VA Medical Center, Cincinnati, Ohio | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director ensures all patient incidents are entered into the VHA Patient Safety Information System and monitors compliance.
Closure Date:
2 The Chief of Staff ensures clinical managers initiate Focused Professional Practice Evaluations that include clearly delineated timeframes and monitors compliance.
Closure Date:
3 The Chief of Staff ensures clinical managers consistently collect and review Ongoing Professional Practice Evaluation data and monitors compliance.
Closure Date:
4 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
5 The Associate Director ensures bottom shelves in equipment storage areas are solid or have impervious shelf liners and monitors compliance.
Closure Date:
6 The Director ensures that the Alternate Control Substance Coordinator’s position description or functional statement includes an addendum for the Control Substance Coordinator’s duties and monitors compliance.
Closure Date:
7 The Director ensures that all Controlled Substance Inspectors complete the physical inventory of the controlled substance storage areas on the same day initiated and monitors compliance.
Closure Date:
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| 18-00412-173 | Comprehensive Healthcare Inspection Program Review of the William Jennings Bryan Dorn VA Medical Center, Columbia, South Carolina | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures Service Chiefs complete required elements of Focused Professional Practice Evaluations for review by the Medical Executive Board and monitors compliance.
Closure Date:
2 The Chief of Staff ensures that Service Chiefs include all required elements for Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
3 The Associate Director ensures all required team members consistently participate on environment of care rounds and monitor compliance.
Closure Date:
4 The Associate Director ensures that Facility managers maintain a safe and clean environment throughout the Facility and monitors compliance.
Closure Date:
5 The Associate Director ensures all medical equipment is identified as safe for patient use and monitors compliance.
Closure Date:
6 The Chief of Staff ensures providers complete suicide risk assessments, within the required timeframe, for patients with positive Post-Traumatic Stress Disorder screens and monitors providers’ compliance.
Closure Date:
7 The Chief of Staff ensures that geriatric evaluation program performance improvement activities are presented to an appropriate leadership board and monitors compliance.
Closure Date:
8 The Chief of Staff ensures that clinicians accurately identify and implement the Geriatric Evaluation plan of care interventions and monitors compliance.
Closure Date:
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| 18-00605-174 | Comprehensive Healthcare Inspection Program Review of the VA Sierra Nevada Health Care System, Reno, Nevada | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director requires the Patient Safety Manager to ensure completion of the required minimum of eight root cause analyses each fiscal year and monitors the Patient Safety Manager’s compliance.
Closure Date:
2 The Chief of Staff ensures that service chiefs include service-specific performance data for Ongoing Professional Practice Evaluations and monitors compliance.
Closure Date:
3 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
4 The Associate Director requires the Nutrition and Food Services Chief to develop and implement a Hazard Analysis Critical Control Point Food Safety plan and monitors the Chief’s compliance.
Closure Date:
5 The Associate Director requires the Nutrition and Food Services Chief to establish a food service-focused inspection process to occur at no less than quarterly intervals and monitors compliance.
Closure Date:
6 The Associate Director requires the Nutrition and Food Services Chief to ensure that food items are properly labeled and monitors compliance.
Closure Date:
7 The Chief of Staff ensures that providers complete suicide risk assessments, within the required timeframe, for patients with positive post-traumatic stress disorder screens and monitors the providers’ compliance.
Closure Date:
8 The Associate Director for Patient Care Services ensures that nursing staff involved in managing central lines receive the required central line-associated bloodstream infection prevention education and monitors staff compliance.
Closure Date:
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11259