Recommendations
2103
| ID | Report Number | Report Title | Type | |
|---|---|---|---|---|
| 25-02192-39 | Review of Leaders’ Actions Affecting Clinical Services at the Syracuse VA Medical Center in New York | Hotline Healthcare Inspection | ||
1 The New York/New Jersey VA Healthcare Network Director evaluates the circumstances that led to Network and Syracuse VA Medical Center leaders not following clinical restructuring requirements according to VHA Directive 1043.
2 The Syracuse VA Medical Center Director evaluates the implementation of high reliability organization principles when communicating changes to clinical operations that include stakeholders, service and section leaders, and staff input.
3 The Syracuse VA Medical Center Director evaluates facility contract processes and takes action to ensure leaders maintain adequate oversight of contracting milestones.
4 The Syracuse VA Medical Center Director evaluates the communication of established contingency plans and ensures alignment with high reliability organization principles.
5 The Syracuse VA Medical Center Director ensures the monitoring and evaluation of patient transfers according to Veterans Health Administration Directive 1094(1) and takes action as warranted.
6 The Syracuse VA Medical Center Director ensures annual procedural complexity designation infrastructure reviews are completed accurately and ensures administrative actions are performed as required.
7 The New York/New Jersey VA Healthcare Network Director evaluates fiscal year 2026 procedural complexity designation infrastructure reviews for all Veterans Integrated Service New York/New Jersey VA Health Care Network facilities and takes action to ensure reviews are accurate and deficiencies are addressed as required.
8 The Under Secretary for Health ensures a timeliness expectation for infrastructure waiver submissions pursuant to Veterans Health Administration Directive 1220(1).
| ||||
| 24-00560-29 | National Review of Mental Health Integration and Suicide Risk Identification in Audiology Clinic Settings | National Healthcare Review | ||
1 The Under Secretary for Health clarifies the requirements for suicide risk and intervention training for audiologists and delineates responsibility for ensuring training is completed as required.
2 The Under Secretary for Health evaluates the definition of healthcare provider for the purposes of suicide risk and intervention training.
3 The Under Secretary for Health evaluates the accuracy of suicide risk and intervention training assignment, consistent with Veterans Health Administration policy, for all healthcare providers.
4 The Under Secretary for Health ensures audiology staff complete suicide risk identification screening as required.
5 The Under Secretary for Health evaluates oversight of and barriers to mental health integration in audiology services and takes action as appropriate.
| ||||
| 25-00631-211 | Supplemental Review of VHA Recruitment, Relocation, and Retention Incentive Service Obligations | Review | ||
1 Enforce procedures for Veterans Health Administration human resources officials to monitor employee service obligations and initiate a debt notice when an employee breaches that agreement, if warranted.
2 Identify and review active incentives of Veterans Health Administration employees who transferred within or left VA and take action, if appropriate.
3 Establish enhanced internal controls to ensure compliance with the law on recruitment, relocation, and retention incentives and take appropriate action when an employee with an active service obligation transfers within the Veterans Health Administration.
4 Complete the evaluation of the incentives awarded to the employees identified in this report who may not have fulfilled their service obligations, determine whether a debt was incurred, and take any appropriate action.
| ||||
| 24-02987-27 | Review of Care Provided to a Patient Who Died by Suicide, Marion VA Health Care System in Illinois | Hotline Healthcare Inspection | ||
1 The Marion VA Health Care System Director ensures a review is conducted of the care provided to the patient by the primary care provider and the neurologist, consults with Human Resources and General Counsel Offices, and takes action as warranted.
Closure Date:
2 The Marion VA Health Care System Director ensures primary care nursing staff’s adherence to facility fall prevention policy and monitors compliance.
3 The Marion VA Health Care System Director evaluates the facility fall prevention policy to consider expectations for mental health staff’s role in responding to patient reports of falls at home.
4 The Marion VA Health Care System Director reviews processes to ensure primary care and specialty care staff are appropriately educated and trained on making referrals to and the services available through the facility’s Traumatic Brain Injury Polytrauma Clinic.
Closure Date:
5 The Marion VA Health Care System Director ensures compliance with the primary care program facility policy concerning specialty consultation staff’s communication with a patient’s primary care provider regarding patient concerns.
6 The Marion VA Health Care System Director ensures compliance with the facility patient problem list standard operating procedure.
7 The Marion VA Health Care System Director strengthens processes to ensure compliance with Veterans Health Administration timeliness standards for obtaining and scanning community care records.
8 The Marion VA Health Care System Director reviews facility care coordination practices between primary care providers and community care providers, identifies barriers to sharing patient treatment information to inform clinical decision-making, and takes action as warranted.
9 The Marion VA Health Care System Director ensures community care staff adhere to requirements regarding completion of community care-care coordination plan notes and monitors compliance.
10 The Marion VA Health Care System Director conducts a review of the facility primary care scheduling processes to ensure compliance with Veterans Health Administration and facility policy on care coordination within Patient Aligned Care Teams.
11 The Marion VA Health Care System Director ensures suicide prevention staff document high-risk flag inactivation within patients’ electronic health records and notify patients when a high-risk flag is activated or inactivated as required by the Veterans Health Administration, and monitors compliance.
12 The Marion VA Health Care System Director ensures mental health staff adhere to Veterans Health Administration requirements on safety planning during high risk for suicide patient record flag patient contacts.
13 The Marion VA Health Care System Director evaluates the care provided to the patient, determines if an institutional disclosure is warranted, and takes action as indicated.
Closure Date:
| ||||
| 24-03520-20 | Mental Health Inspection of the Martinsburg VA Medical Center in West Virginia | Mental Health Inspection Program | ||
1 The Facility Director ensures regular communication between mental health and executive leaders regarding staffing needs and mental health processes.
2 The Facility Director ensures the Mental Health Executive Council operates in accordance with Veterans Health Administration requirements.
3 The Chief of Mental Health ensures a full-time, dedicated local recovery coordinator is integrated into the inpatient mental health unit to support recovery-oriented care.
4 The Chief of Mental Health ensures mental health leaders develop and implement written processes for staff training, education, and recovery-oriented services.
5 The Chief of Mental Health ensures staff provide a minimum of four hours of recovery-oriented, interdisciplinary mental health programming on weekdays and weekends.
6 The Facility Director ensures veterans’ privacy in the communal shower room on the inpatient mental health unit.
7 The Facility Director ensures clinicians document veterans’ capacity to consent to admission to the inpatient mental health unit.
8 The Veterans Integrated Service Network Director ensures facilities’ involuntary hold and hospitalization processes align with applicable state laws and develops processes for ongoing oversight.
9 The Facility Director consults with District Counsel to establish written involuntary hold and hospitalization processes that align with West Virginia State laws and monitors compliance.
10 The Facility Director develops and implements written care coordination processes for veterans involuntarily admitted to non-VA healthcare facilities.
11 The Chief of Staff ensures providers document discussions with veterans on the risks and benefits of newly prescribed medications and monitors for compliance.
12 The Chief of Staff ensures veterans’ discharge instructions are written in easy-to-understand language and include the follow-up appointment location, the purpose of each medication, and an explanation when both trade and generic names are used for the same medication.
13 The Facility Director ensures staff comply with suicide prevention training requirements and monitors for compliance.
14 The Facility Director ensures Interdisciplinary Safety Inspection Team members participate in Mental Health Environment of Care Checklist inspections and document membership and attendance.
15 The Facility Director ensures the Interdisciplinary Safety Inspection Team accurately identifies, documents, and addresses safety hazards within the Patient Safety Assessment Tool and monitors for compliance.
16 The Facility Director directs staff to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.
| ||||
| 25-00729-23 | Mental Health Inspection of the VA NY Harbor Healthcare System in New York | Mental Health Inspection Program | ||
1 The Associate Chief of Staff, Mental Health ensures compliance with Veterans Health Administration requirements for a full-time local recovery coordinator.
Closure Date:
2 The Associate Chief of Staff, Mental Health ensures the implementation of written processes for staff training, education, and recovery-oriented services.
3 The Facility Director identifies and addresses barriers to communal room access for veterans on the inpatient unit.
4 The Facility Director ensures accurate reporting of inpatient mental health beds and implements processes to monitor.
5 The Facility Director formalizes written processes to monitor and track compliance with state involuntary commitment requirements.
6 The Facility Director ensures staff document veterans’ legal commitment status in the electronic health record and monitors for compliance.
7 The Chief of Staff ensures documentation of discussions between prescribers and veterans on the risks and benefits of newly prescribed medications and monitors for compliance.
8 The Chief of Staff ensures discharge instructions for veterans include appointment locations written in easy-to-understand language.
9 The Chief of Staff ensures discharge instructions for veterans include the purpose for each medication listed and are free of medical abbreviations.
10 The Chief of Staff directs staff to complete and document the Columbia-Suicide Severity Rating Scale within 24 hours before veterans’ discharge and monitors for compliance.
11 The Chief of Staff directs staff to complete suicide prevention safety plans and provide copies of the plans to veterans or caregivers and monitors for compliance.
12 The Chief of Staff directs staff to address ways to make veterans’ environments safer from potentially lethal means, beyond firearms and opioids, in safety plans and monitors for compliance.
13 The Under Secretary for Health identifies barriers to, and ensures documentation of, discussions specific to making the environment safer from identified lethal means in veterans’ safety plans.
14 The Facility Director directs staff to comply with suicide prevention training requirements and monitors for compliance.
15 The Facility Director ensures compliance with Veterans Health Administration requirements for the Interdisciplinary Safety Inspection Team, including recording of meeting minutes, membership, and attendance, and monitors for compliance.
16 The Facility Director implements processes to ensure the Interdisciplinary Safety Inspection Team applies Mental Health Environment of Care Checklist standards on the inpatient mental health unit and monitors for compliance.
17 The Facility Director directs inpatient unit staff and Interdisciplinary Safety Inspection Team members to comply with Mental Health Environment of Care Checklist training requirements and monitors for compliance.
| ||||
| 25-00205-26 | Healthcare Facility Inspection of the VA Gulf Coast Healthcare System in Biloxi, Mississippi | Healthcare Facility Inspection | ||
1 The Associate Medical Center Director ensures Environmental Management Services and nutrition staff maintain clean patient food storage areas.
2 The Associate Medical Center Director ensures staff monitor storage areas and remove expired supplies.
3 The Associate Medical Center Director ensures Environmental Management Services staff make feminine hygiene products available in public women’s and unisex restrooms.
4 The Chief of Staff ensures staff establish written service-level workflows for the communication of test results.
| ||||
| 24-03206-21 | Healthcare Facility Inspection of the VA Clarksburg Healthcare System in West Virginia | Healthcare Facility Inspection | ||
1 Executive leaders ensure staff store clean and dirty equipment separately, repair torn furnishings, and keep the environment clean.
2 Executive leaders ensure staff evaluate the cardboard backboards for pest concerns and reduce the risk of infection.
Closure Date:
3 Executive leaders ensure the facility’s policy for test result communication aligns with the VHA directive.
| ||||
| 23-02182-185 | Independent Audit Report of Pharma Logistics LLC’s Billing Compliance | Audit | ||
1 Confer with the Office of General Counsel regarding the potential recovery of the $4.4 million in manufacturer credits that were issued by manufacturers and retained by Pharma Logistics before the associated jobs were closed.
2 Contact the Office of General Counsel regarding the potential recovery of unsupported discrepancies between the total credits received and amounts disbursed.
3 Contact the Office of General Counsel regarding the potential recovery of unsupported return credits to manufacturers.
Closure Date:
| ||||
| 25-00199-19 | Healthcare Facility Inspection of the VA Tampa Healthcare System in Florida | Healthcare Facility Inspection | ||
1 Facility leaders ensure staff have access to sinks or hand hygiene supplies in or near soiled utility rooms that store biohazardous materials.
Closure Date:
2 Facility leaders assess how staff monitor video laryngoscope supplies to ensure they are readily available, and staff remove supplies when they expire.
3 Facility leaders ensure staff develop service-level workflows for the communication of test results per the VHA directive.
| ||||
15169