Recommendations
1332
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 17-01742-90 | Comprehensive Healthcare Inspection Program Review of the West Texas VA Health Care System, Big Spring, Texas | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures clinicians consistently provide patient education specific for newly prescribed anticoagulant medications and monitors compliance.
Closure Date:
2 The Chief of Staff ensures clinicians consistently obtain all required laboratory tests prior to initiating warfarin and monitors compliance.
Closure Date:
3 The Chief of Staff ensures that for emergent transfers, provider transfer notes document patient stability for transfer and provision of all medical care within the facility’s capacity and monitors providers’ compliance.
Closure Date:
4 The Chief of Staff ensures that for patients transferred out of the facility, providers document sending or communicating to the accepting facility pertinent patient information and monitors providers’ compliance.
Closure Date:
5 The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees document details of the observations and deficiencies identified during monthly self-inspections, submit work orders for all items needing repair, and document corrective actions taken, and the Chief of Staff monitors employees’ compliance.
Closure Date:
6 The Chief of Staff ensures that Mental Health Residential Rehabilitation Treatment Program employees consistently conduct and document weekly contraband inspections and monitors employees’ compliance.
Closure Date:
7 The Associate Director ensures that Mental Health Residential Rehabilitation Treatment Program managers ensure that all doors not considered as the main point of entry have audible alarms and monitors managers’ compliance.
Closure Date:
8 The Chief of Staff ensures that acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
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9 The Chief of Staff ensures that acceptable providers offer further diagnostic evaluations to patients with positive post-traumatic stress disorder screens and refer them and monitors providers’ compliance.
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10 The Chief of Staff ensures that acceptable providers complete diagnostic evaluations within 30 days for patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
11 The Chief of Staff ensures that resident physicians are assigned and granted the correct user class computer option and that clinical managers review and monitor residents’ progress notes to ensure that resident supervision documentation meets requirements, and the Chief of Staff monitors managers’ compliance.
Closure Date:
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| 17-01855-81 | Comprehensive Healthcare Inspection Program Review of the Wilkes-Barre VA Medical Center, Wilkes-Barre, Pennsylvania | Comprehensive Healthcare Inspection Program | ||
1 The Associate Director ensures required team members participate on environment of care rounds and monitors compliance.
Closure Date:
2 The Associate Director ensures a safe respiratory environment for patients and employees in the Community Living Center units and monitors compliance.
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3 The Chief of Staff and Associate Director for Patient Care Services ensure social workers and registered nurses conduct cyclical clinical visits with the required frequency and monitor compliance.
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| 17-01853-89 | Comprehensive Healthcare Inspection Program Review of the Alexandria VA Health Care System, Pineville, Louisiana | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff ensures that clinical managers consistently review Ongoing Professional Practice Evaluation data at least every 6 months and monitors managers’ compliance.
Closure Date:
2 The Chief of Staff ensures clinicians consistently provide specific education to patients with newly prescribed anticoagulant medications and monitors clinicians’ 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 Associate Director ensures that facility managers maintain a safe and clean environment in all patient care areas and monitors the managers’ compliance.
Closure Date:
5 The Associate Director ensures locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors compliance.
Closure Date:
6 The Chief of Staff ensures the Community Nursing Home Oversight Committee includes consistent representation by the medical staff and monitors compliance.
Closure Date:
7 The Chief of Staff ensures social workers and registered nurses conduct alternating, cyclical clinical visits with the required frequency and monitors their compliance.
Closure Date:
8 The Chief of Staff ensures acceptable providers perform and document suicide risk assessments for all patients with positive post-traumatic stress disorder screens and monitors providers’ compliance.
Closure Date:
9 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:
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| 15-03059-384 | Review of Alleged Funding Security Issues of the Veterans Services Adaptable Network at VA Medical Center Orlando, FL | Audit | ||
1 The OIG recommended the executive in charge for the Office of the Under Secretary for Health, in conjunction with the executive in charge for the Office of Information and Technology, ensure that all guest internet access networks, external air gapped networks, and industrial control systems are appropriately segregated from VA networks and meet the department’s information security requirements.
Closure Date:
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| 17-01760-85 | Comprehensive Healthcare Inspection Program Review of the Huntington VA Medical Center, Huntington, West Virginia | Comprehensive Healthcare Inspection Program | ||
1 The Facility Director requires the Quality, Safety, and Value Council to document meeting minutes that include evidence of the review and analysis of aggregated data, identification of opportunities for improvement, implementation of corrective actions, and evaluation of effectiveness of the actions and monitors the Quality, Safety, and Value Council’s compliance.
Closure Date:
2 The Associate Director for Patient Care Services ensures that for patients transferred out of the facility, sending nurses document transfer assessments/notes and monitors the nurses’ compliance.
Closure Date:
3 The Chief of Staff ensures that for patients transferred out of the facility, providers communicate with or send to the accepting facility pertinent patient information and monitors providers’ compliance.
Closure Date:
4 The Associate Director ensures required team members consistently participate on environment of care rounds and monitors compliance.
Closure Date:
5 The Associate Director ensures access to sterile supplies at the Gallipolis community based outpatient clinic is restricted and monitors compliance.
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6 The Associate Director ensures medical (biohazardous) waste stored for pick-up at the Gallipolis community based outpatient clinic is secured and monitors compliance.
Closure Date:
7 The Chief of Staff ensures the Community Nursing Home Oversight Committee includes a representative from acquisitions.
Closure Date:
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| 17-04460-84 | Combined Assessment Program Summary Report— Management of Disruptive and Violent Behavior in Veterans Health Administration Facilities | Comprehensive Healthcare Inspection Program | ||
1 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure Facility Directors establish Employee Threat Assessment Teams.
Closure Date:
2 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require attendance by VA Police Officers, Patient Safety and/or Risk Management Officials, and Patient Advocates at Disruptive Behavior Committee/Board meetings and monitor compliance.
Closure Date:
3 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that when Chiefs of Staff (or designees) issue Orders for Behavioral Restriction, they document that they informed patients that the Orders were issued and of the right to appeal the decisions and that facility senior managers monitor compliance.
Closure Date:
4 OIG recommended that the Executive in Charge, Office of the Under Secretary forHealth, in conjunction with Veterans Integrated Service Network senior managers, ensure facility senior managers require that within 90 days of hire, all employees complete Level I Prevention and Management of Disruptive Behavior training and additional training levels based on the type and severity of risk for exposure to disruptive and unsafe behaviors and monitor compliance.
Closure Date:
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| 16-03405-80 | Healthcare Inspection – Primary Care Provider’s Clinical Practice Deficiencies and Security Concerns, Fort Benning VA Clinic, Fort Benning, Georgia | Hotline Healthcare Inspection | ||
1 We recommended that the Veterans Integrated Service Network Director ensure that the System Director evaluates the care of the subject patient (Patient 1) and consults with the Office of General Counsel for disclosure to the patient, if appropriate.
Closure Date:
2 We recommended that the Veterans Integrated Service Network Director ensure that the System Director consults with the Office of Human Resources and the Office of General Counsel to determine the appropriate administrative action(s), if any, for Primary Care Provider X and Primary Care Provider X’s supervisors.
Closure Date:
3 We recommended that the System Director ensure that providers notify patients of test values and follow up on clinical laboratory results as required.
Closure Date:
4 We recommended that the System Director ensure that providers accurately document patients’ assessment, diagnosis, and treatment information into the electronic health record.
Closure Date:
5 We recommended that the System Director ensure that consults for VHA and non-VA care are entered and completed within time frames set by Veterans Health Administration.
Closure Date:
6 We recommended that the System Director ensure that employees receive training appropriate for the assigned Workplace Behavioral Risk Assessment risk level.
Closure Date:
7 We recommended that the System Director ensure that Clinic employees are trained in emergency management procedures.
Closure Date:
8 We recommended that the System Director ensure that emergency procedures and contact information are posted and readily available to Clinic employees.
Closure Date:
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| 17-01744-69 | Comprehensive Healthcare Inspection Program Review of the Grand Junction Veterans Health Care System, Grand Junction, Colorado | Comprehensive Healthcare Inspection Program | ||
1 The Chief of Staff 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 the Patient Safety Manager consistently provides feedback to employees or departments who submit close call and adverse event reports that result in a root cause analysis and monitors the manager’s compliance.
Closure Date:
3 The Chief of Staff ensures anticoagulation program managers establish a defined process for anticoagulation-related calls outside normal business hours and monitors compliance with the process.
Closure Date:
4 The Chief of Staff ensures the Pharmacy and Therapeutics Committee reviews anticoagulation data quarterly and monitors the committee’s compliance.
Closure Date:
5 The Facility Director ensures inter-facility patient transfer data are reported to a quality oversight committee and monitors compliance.
Closure Date:
6 The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently include in transfer documentation patient or surrogate informed consent and monitors the clinicians’ compliance.
Closure Date:
7 The Chief of Staff ensures that for patients transferred out of the facility, clinicians consistently document sending or communicating pertinent patient information to the receiving facility and monitors the clinicians’ compliance.
Closure Date:
8 The Associate Director ensures core team members consistently attend environment of care rounds and monitors compliance.
Closure Date:
9 The Associate Director ensures all locked mental health unit employees and Interdisciplinary Safety Inspection Team members complete the required training on how to identify and correct environmental hazards, including the proper use of the Mental Health Environment of Care Checklist, and monitors employees’ and team members’ compliance.
Closure Date:
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| 15-01005-18 | Audit of VHA's Use of Appropriations to Develop a System Enhancement and Mobile Health Application | Audit | ||
1 The OIG recommended the Acting Assistant Secretary for the Office of Information and Technology ensure the new directive reflects updates so that new and emerging advances in information technology are included.
Closure Date:
2 The OIG recommended the Acting Under Secretary for Health ensure VHA’s Chief Financial Officer, in consultation with VA’s Chief Financial Officer and Office of General Counsel, determine which medical care appropriation VHA should use for mobile health application development and notify VHA staff offices accordingly.
Closure Date:
3 The OIG recommended the Acting Assistant Secretary for the Office of Management issue a memorandum reiterating the importance of complying with the United States Code, Federal Regulations, and VA’s current policies on the proper use of appropriations.
Closure Date:
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| 16-02864-71 | Healthcare Inspection – Delays in Processing Release of Information Requests, Bay Pines VA Healthcare System, Bay Pines, Florida | Hotline Healthcare Inspection | ||
1 We recommended that the System Director ensure strengthening of procedures for timely processing of Release of Information requests.
Closure Date:
2 We recommended that the System Director strengthen the process to adequately capture and trend complaints related to Release of Information requests in accordance with Veterans Health Administration policy.
Closure Date:
3 We recommended that the System Director ensure an evaluation of the personnel issues negatively impacting staff retention and hiring in the Release of Information section and take appropriate action.
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4 We recommended that the System Director ensure accurate monitoring of Release of Information staff productivity.
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5 We recommended that the System Director ensure accurate and effective trackingand monitoring processes of Release of Information requests.
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6 We recommended that the System Director ensure consultation with the Office ofHuman Resources and the Office of General Counsel to determine the appropriateadministrative action, if any, for managers’ performance related to implementation ofcorrective action plans in response to privacy violations.
Closure Date:
7 We recommended that the System Director ensure Release of Information standardoperating procedures are established in accordance with VHA policy and implemented consistently.
Closure Date:
8 We recommended that the System Director strengthen working relationships andcommunication processes within the facility Release of Information section andamongst staff and Business Office Service managers.
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11259