Recommendations
2051
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 24-00549-56 | Healthcare Facility Inspection of the VA Salem Healthcare System in Virginia | Healthcare Facility Inspection | ||
1 The Executive Director mitigates the impact of construction on patient care in the Emergency Department.
2 The Chief of Staff ensures the toxic exposure screening navigators verify data to track veterans waiting for secondary screenings and address any backlog.
Closure Date:
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| 24-01219-12 | Lapse in Fiduciary Program Oversight Puts Some Vulnerable Beneficiaries at Risk | Review | ||
1 Establish Veterans Benefits Management System–Fiduciary records for the 311 identified beneficiaries within the Veterans Benefits Management System.
Closure Date:
2 Start or resume required oversight activities, such as field examinations, to assess the well-being and protection of VA funds for the 311 identified beneficiaries.
Closure Date:
3 Implement controls to identify when beneficiaries deemed incompetent do not have electronic fiduciary records and to ensure records are established in the required system(s).
Closure Date:
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| 24-00234-53 | Deficiencies in Invasive Procedure Complexity Infrastructure, Surgical Resident Supervision, Information Security, and Leaders’ Response at the Lieutenant Colonel Charles S. Kettles VA Medical Center in Ann Arbor, Michigan | Hotline Healthcare Inspection | ||
1 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that service chiefs responsible for required invasive procedure infrastructure services ensure the completion of the annual review of infrastructure and that existing infrastructure is accurately reported.
Closure Date:
2 The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures that requirements and processes for invasive procedure complexity infrastructure waiver requests are clearly communicated to facility leaders.
Closure Date:
3 The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director reviews the process for tracking invasive procedure complexity infrastructure waiver requests, and takes actions as needed to avoid delays in review and submission.
Closure Date:
4 The Under Secretary for Health ensures that guidance provided to Veterans Integrated Service Network and facility leaders regarding the invasive procedure complexity infrastructure waiver request process is clear and consistent with Veterans Health Administration Directive 1220(1).
5 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director confirms that acute and emergent patient transfer times related to waived infrastructure requirements are tracked and monitored, identifies trends or adverse patient outcomes, and takes actions as warranted.
6 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director directs the chief of surgery, or designee, to attend blood utilization review committee meetings per facility requirements, and ensures compliance.
7 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews the care provided to patient B to confirm compliance with Veterans Health Administration Directive 1004.08, determines if an institutional disclosure is warranted, and takes action as required.
Closure Date:
8 The Under Secretary for Health reviews Veterans Health Administration Directive 1400.01 to confirm that the supervision of PGY-1 surgery residents and guidance provided to Veterans Health Administration facilities aligns with Veterans Health Administration policy and Accreditation Council for Graduate Medical Education program requirements.
9 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director ensures that operative documentation is completed per facility policy, reviews the methodology for monitoring operative documentation compliance, and takes action as necessary.
Closure Date:
10 The Lieutenant Colonel Charles S. Kettles VA Medical Center Director reviews and monitors staff and health professional trainee compliance with the rules of behavior as it applies to authorized access to all VA computer programs including clinical applications.
Closure Date:
11 The Under Secretary for Health evaluates the process for granting authorized access to VA computer systems for health profession trainees and takes steps to ensure access is provided by the start of trainee rotations at VA facilities.
12 The VA Healthcare System Serving Ohio, Indiana, and Michigan Network Director ensures the corrective actions developed by facility leaders to address surgical intensive care unit patient safety concerns are completed and evaluated for effectiveness.
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| 23-01609-14 | Atlanta Call Center Staffing and Operational Challenges Provide Lessons for the New VISN 7 Clinical Contact Center | Review | ||
1 Use up-to-date contact center data and the recommended Veterans Health Administration call center staffing model to ensure the clinical contact center is operating within indicated target staffing goals.
2 Evaluate call center staffing and call data for clinical contact center staff based at the Atlanta facility to identify possible operational inefficiencies related to scheduling, handle time, and availability for calls, and address inefficiencies as needed.
3 Periodically evaluate the performance of health administration services staff who answer specialty care clinic calls at the Atlanta facility to ensure they meet Veterans Health Administration call center performance standards.
4 Evaluate call data to ensure health administration services staff at the Atlanta facility who answer calls for the mental health and specialty care clinics meet Veterans Health Administration call center performance standards for timeliness and abandonment rate.
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| 24-01598-43 | Deficiencies in Case Management and Access to Care for HUD-VASH Veterans at the VA Greater Los Angeles Healthcare System in California | Hotline Healthcare Inspection | ||
1 The Greater Los Angeles Healthcare System Director ensures veterans enrolled in the Housing and Urban Development Veterans Affairs Supportive Housing program have documented treatment plans consistent with Veterans Health Administration and facility policy.
2 The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors’ electronic health record review process to assess Housing and Urban Development Veterans Affairs Supportive Housing-related documentation, including treatment plan deficiencies, and takes action as warranted.
3 The Greater Los Angeles Healthcare System Director ensures facility Housing and Urban Development Veterans Affairs Supportive Housing program discharge policy is in alignment with Veterans Health Administration policy.
4 The Greater Los Angeles Healthcare System Director reviews and assesses the Housing and Urban Development Veterans Affairs Supportive Housing program supervisors’ process to identify incongruencies between electronic health records and Homeless Operations Management and Evaluation System documentation, and takes action as warranted.
5 The Greater Los Angeles Healthcare System Director reviews patient aligned care team assignments for unhoused Housing and Urban Development Veterans Affairs Supportive Housing veterans, and takes action as warranted.
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| 24-01751-39 | Improvements in Patient Safety, but Concerns Identified with Staffing Shortages Affecting Quality of Care at the VA Community Living Center in Miles City, Montana | Hotline Healthcare Inspection | ||
1 The VA Montana Healthcare System Director reviews Community Living Center physician coverage to identify barriers and gaps, determines options for resolution, and completes and executes a coverage plan to ensure residents’ care and staff’s needs are met when the physician is not available for extended periods.
Closure Date:
2 The VA Montana Healthcare System Director reviews Community Living Center physical therapy staffing to identify barriers and gaps, determines options for resolution, and completes and executes a hiring plan to ensure residents’ care and staff’s needs are met.
Closure Date:
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| 24-00194-42 | Leaders Failed to Ensure a Dermatologist Provided Quality Care at the Carl T. Hayden VA Medical Center in Phoenix, Arizona | Hotline Healthcare Inspection | ||
1 The Carl T. Hayden Medical Center Director ensures that supervisory staff take effective actions to correct clinical deficiencies.
2 The Carl T. Hayden Medical Center Director identifies electronic health records containing the dermatologist’s misuse of copy and paste and takes action as warranted to ensure the safety of patients.
3 The Carl T. Hayden Medical Center Director ensures that service chiefs and patient safety staff report instances of misuse of copy and paste to Health Information Management System staff.
4 The Carl T. Hayden Medical Center Director ensures a comprehensive review is conducted to determine if the dermatologist documented electrodesiccation and curettage procedures that were not performed and takes action as warranted, including providing patients with clinical care and disclosures if needed, and notifying the Office of Inspector General.
5 The Carl T. Hayden Medical Center Director ensures that the Chief of Staff is aware of and addresses pervasive deficiencies, when they exist, in clinical care provided at the facility.
6 The Desert Pacific Healthcare System Network Director evaluates reasons for noncompliance with the state licensing board reporting policy with regard to the dermatologist, and takes action as needed.
7 The Carl T. Hayden Medical Center Director ensures that a dermatologist conducts a review of the dermatologist’s patients with consideration of the concerns laid out in this report, to identify patients who may need follow-up care and disclosures, and takes action as warranted.
8 The Carl T. Hayden Medical Center Director reviews with facility leaders, disclosure requirements outlined in VHA Directive 1004.08, Disclosure of Adverse Events to Patients.
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| 24-00566-16 | Care in the Community Inspection of VA Sierra Pacific Network (VISN 21) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per fiscal year.
Closure Date:
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.
Closure Date:
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
Closure Date:
4 The Veteran Integrated Service Network Director, in conjunction with facility directors, ensures facility staff scan all community care documents into the patient’s electronic health record within five business days of receipt.
Closure Date:
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended their appointments and attempt to obtain medical documentation prior to administratively closing consults.
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative closure of consults that are not low risk.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to community providers for requests for additional services.
Closure Date:
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send approval or denial letters to patients for requests for additional services.
Closure Date:
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff schedule patients for community care appointments within seven days of consult entry or receipt in the department.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff confirm patients attended scheduled community care appointments and received care.
13 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff use the Community Care–Care Coordination Plan note to document all care coordination activities for consults with an assigned level of care other than basic.
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| 23-01739-26 | Care in the Community Inspection of VA Desert Pacific Healthcare Network (VISN 22) and Selected VA Medical Centers | Care in the Community Healthcare Inspection | ||
1 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures community care oversight councils function according to their charters and meet the required number of times per calendar year.
2 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff complete the operating model staffing tool reassessment every 90 days.
Closure Date:
3 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff enter community care patient safety events into the Joint Patient Safety Reporting system.
Closure Date:
4 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures patient safety managers or designees brief community care patient safety event trends, lessons learned, and corrective actions at community care oversight council meetings.
5 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures VHA staff scan all community care documents into the patient’s electronic health record within five business days of receipt.
6 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff attach diagnostic imaging results to the Community Care Consult Result note.
Closure Date:
7 The Veterans Integrated Service Network Director, in conjunction with facility directors, requires facility community care staff to use the significant findings alert to notify the ordering provider of abnormal diagnostic imaging results.
8 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff make two additional attempts to obtain community providers’ medical documentation within 90 days of the appointment following administrative consult closure.
9 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff process community care providers’ requests for additional services within three business days of receipt.
10 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff incorporate requests for additional services and supporting medical documentation in patients’ electronic health records.
11 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff verify community care providers’ signatures on requests for additional services forms.
12 The Veterans Integrated Service Network Director, in conjunction with facility directors, ensures facility community care staff send letters to community providers when they deny requests for additional services.
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| 24-00587-45 | Healthcare Facility Inspection of the VA Southern Oregon Healthcare System in White City | Healthcare Facility Inspection | ||
1 The OIG recommends facility leaders relocate papers and folders outside of patient examination rooms or secure them in protective coverings to mitigate the risk of infection.
Closure Date:
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14903